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RECOGNITION OF EMOTIONAL FACIAL EXPRESSIONS IN ALCOHOL DEPENDENT INPATIENTS
A THESIS SUBMITTED TO THE GRADUATE SCHOOL OF SOCIAL SCIENCES
OF MIDDLE EAST TECHNICAL UNIVERSITY
BY
PINAR DURSUN
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF SCIENCE IN
PSYCHOLOGY
JUNE 2007
Approval of the Graduate School of (Name of the Graduate School) Prof. Dr. Sencer Ayata
Director
I certify that this thesis satisfies all the requirements as a thesis for the degree of Master of Science
Prof. Dr. Nebi Sümer Head of Department This is to certify that we have read this thesis and that in our opinion it is fully adequate, in scope and quality, as a thesis for the degree of Master of Science.
Assoc. Prof. Faruk Gençöz Supervisor
Assoc. Prof. Adnan Cansever (GATA)
Assoc. Prof. Faruk Gençöz (METU, PSY)
Dr. Özlem Bozo (METU, PSY)
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I hereby declare that all information in this document has been obtained and presented in accordance with academic rules and ethical conduct. I also declare that, as required by these rules and conduct, I have fully cited and referenced all material and results that are not original to this work.
Name, Last name: Pınar Dursun
Signature :
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ABSTRACT
RECOGNITION OF EMOTIONAL FACIAL EXPRESSION IN ALCOHOL DEPENDENT INPATIENTS
Dursun, Pınar
M.S., Department of Psychology
Supervisor: Assoc. Prof. Faruk Gençöz
June 2007, 130 pages
The ability to recognize emotional facial expressions (EFE) is very critical for
social interaction and daily functioning. Recent studies have shown that alcohol
dependent individuals have deficits in the recognition of these expressions. Thereby,
the objective of this study was to explore the presence of impairment in the decoding
of universally recognized facial expressions -happiness, sadness, anger, disgust, fear,
surprise, and neutral expressions- and to measure their manual reaction times (RT)
toward these expressions in alcohol dependent inpatients. Demographic Information
Form, CAGE Alcoholism Inventory, State-Trait Anxiety Inventory (STAI), Beck
Depression Inventory (BDI), The Symptom Checklist, and lastly a constructed
computer program (Emotion Recognition Test) were administered to 50 detoxified
alcohol dependent inpatients and 50 matched-control group participants. It was
hypothesized that alcohol dependents would show more deficits in the accuracy of
reading EFE and would react more rapidly toward negative EFE -fear, anger, disgust,
sadness than control group. Series of ANOVA, ANCOVA, MANOVA and
MANCOVA analyses revealed that alcohol dependent individuals were more likely
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to have depression and anxiety disorders than non-dependents. They recognized less
but responded faster toward disgusted expressions than non-dependent individuals.
On the other hand, two groups did not differ significantly in the total accuracy
responses. In addition, the levels of depression and anxiety did not affect the
recognition accuracy or reaction times. Stepwise multiple regression analysis
indicated that obsessive-compulsive subscale of SCL, BDI, STAI-S Form, and the
recognition of fearful as well as disgusted expressions were associated with
alcoholism. Results were discussed in relation to the previous findings in the
literature. The inaccurate identification of disgusted faces might be associated with
organic deficits resulted from alcohol consumption or cultural factors that play very
important role in displaying expressions.
Keywords: Emotion; Emotional Facial Expression; Recognition Accuracy;
Alcoholism
vi
ÖZ
ALKOL BAĞIMLISI OLARAK YATAN HASTALARDA YÜZDEKİ DUYGU İFADELERİNİN ALGILANMASI
Dursun, Pınar
Master, Psikoloji Bölümü
Tez Yöneticisi: Doç. Dr. Faruk Gençöz
Haziran 2007, 130 sayfa
Yüzdeki duygu ifadelerini doğru bir biçimde tanıyabilmek, sosyal etkileşim ve
gündelik işlevsellik adına çok önemlidir. Son yıllarda yapılan çalışmalar, alkol
bağımlılarının yüzdeki duygu dışavurumlarını algılamalarında sorun yaşadıklarını
göstermektedir. Böylece, bu çalışmanın amacı, alkol bağımlılarında evrensel olarak
kabul edilen yüzdeki duygu dışavurumlarının- mutluluk, üzüntü, kızgınlık, iğrenme,
korku, şaşırma ve nötr- algılanmasında bir bozukluk olup olmadığını saptamak ve bu
dışavurumların algılanmasındaki reaksiyon zamanlarını ölçmektir. Bu amaçla, 50
arındırılmış alkol bağımlısı yatan hasta ve eşleştirilmiş 50 kontrol grubu
katılımcılarına, Demografik Bilgi Formu, CAGE Alkol Bağımlılığı Skalası,
Durumluk-Süreklilik Kaygı Envanteri (DSKE), Beck Depresyon Envanteri (BDE),
Ruhsal Belirti Tarama Testi (SCL-90-R) ve son olarak araştırmacılar tarafından
geliştirilmiş “Duygu Tanıma Testi” uygulanmıştır. Hipotezlerimiz; alkol
bağımlılarının kontrol grubuna göre bu dışavurumları algılarken daha fazla hata
yapacağı ve negatif dışavurumlar olan korku, kızgınlık, iğrenme ve üzüntüyü
algılarken daha çabuk reaksiyon göstereceği yönündedir. Uygulanan bir çok
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ANOVA, ANCOVA, MANOVA ve MANCOVA analizleri, alkol bağımlılarının
bağımlı olmayanlara göre daha fazla depresyon ve anksiyete bozukluklarına eğilimi
olduğunu ortaya koymuştur. Bağımlılar, iğrenme ifadesini daha az ancak daha hızlı
algılamışlardır. Öte yandan, iki grup, doğru yanıtlarının toplamında istatistiksel
olarak anlamlı bir farklılık göstermemişlerdir. Ayrıca, depresyon ve anksiyete
düzeylerinin algılama doğruluğunda ya da reaksiyon zamanlarında bir etkisi olmadığı
görülmüştür. Stepwise Regresyon Analizi, SCL’nin obsesif-kompülsif alt ölçeğinin,
BDE’nin, SDKE-D Formunun ve korku ve ek olarak iğrenme duygu
dışavurumlarının algılanmasının alkolizm ile ilişkili olduğunu göstermiştir.
Çalışmanın sonuçları literatürdeki bulgular bağlamında tartışılmıştır. İğrenme
ifadesinin yanlış algılanması, alkol tüketiminin sonucu olan organik bir bozuklukla
ya da ifadelerin yanlış yorumlanmasında rol oynayan kültürel faktörlerle
ilişkilendirilebilir.
Anahtar Sözcükler: Duygu; Yüzdeki Duygu Dışavurumları; Algılama Doğruluğu;
Alkol Bağımlılığı
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To my parents İnci-Ahmet Dursun, my sister Ekin Dixmier
and my dearest friends,
for their love and inspiration…
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ACKNOWLEDGEMENTS
This study is the first achievement of my life. Sometimes, I felt very hopeless
and anxious in order to complete this study properly. I really appreciate to some
people who always supported me and believed in me.
First, I would like to express my deepest gratitude to my supervisor Assoc.
Prof. Faruk Gençöz for his guidance, advice, criticism, encouragements throughout
the study. Also, I would like to thank his beautiful and wise wife, Assoc. Prof. Tülin
Gençöz for her valuable comments and statistical help. It was really pleasure to work
with them and to have been exposed to their original ideas to progress this study.
I would like to thank my commitee members Assoc. Prof. Adnan Cansever,
and Dr. Özlem Bozo for their help, trust, and sincerity.
I would like to express my deepest gratitude to Prof. Dr. Arşaluys Kayır for
her continued warm and supports as well as encouragement that make me feel more
self-confident and relieved.
I am very grateful to Kayhan İnce for his help to construct Emotional
Recognition Test and patience to help me. Additionally, I wish to express my
gratitude to Dr. Refhan Balkan Öztürk for her kind and support and help at collecting
data at Bakırköy Mental and Neurological Diseases Hospital AMATEM clinic, as
well as the clinic staff there.
I would like to thank all the alcohol dependent inpatients and volunteers for
their participation, trust and sincerity.
I owe many thanks to my dearest friends Şafak Çakmak, Irmak Odabaş,
Seyha Hocaoğlu, my editor Evrim Sabak and S. Murat Direr for their love, altruism,
endless encouragement, support, sincere understanding, valuable suggestions, and
finally tolerance as well as patience that helped me to reduce my anxiety and
motivated me even in the hardest time of the thesis process.
Finally, I am forever indepted to my family for their unconditional love, care,
understanding, and trust when I needed most.
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TABLE OF CONTENTS
PLAGIARISM iii ABSTRACT iv ÖZ vi DEDICATION viii ACKNOWLEDGEMENTS ix TABLE OF CONTENTS x LIST OF TABLES xiii LIST OF FIGURES xiv CHAPTER 1. INTRODUCTION
1.1. Emotion 1
1.1.1. Philosophical Background of Emotion 1 1.1.2. Perspectives on Emotion 3 1.1.2.1. Evolutionary Perspective and Charles Darwin 3 1.1.2.2. The Psychodynamic Perspective 5 1.1.2.3. Peripheral Perspective and James-Lange Theory of Emotion 5 1.1.2.4. Central Perspective and Cannon-Bard Theory of Emotion 7 1.1.2.5. Cognitive Perspectives 8 1.1.3. Emotion and Related Concepts: Feeling, Affect, Emotional States, Mood, and Emotional Disorders
10
1.1.4. Emotional Facial Expressions (EFE) 13 1.1.5. Basic or Discrete Emotions 15 1.1.5.1. Basic or Discrete Emotions: Definitions 17 1.1.5.1.a. Happiness 17 1.1.5.1.b. Sadness 19 1.1.5.1.c. Fear 20 1.1.5.1.d. Anger 21 1.1.5.1.e. Surprise 23 1.1.5.1.f. Disgust 25 1.1.6. Universality of Emotional Facial Expressions (EFE) 25 1.1.7.The Neuropsychology of Emotion 28 1.1.7.1. The Hypothalamus 28 1.1.7.2. The Limbic System 28 1.1.7.3. The Cortex 29 1.1.8. The Development of Emotions 30 1.1.8.1. The Development of the Expression of Emotions 31 1.1.9. The Emotional Facial Expression (EFE) and Cognition 32 1.1.9.1. Affective/Mood Disorders, Anxiety Disorders and Recognition of Facial Expressions (EFE): The Literature Review
32
1.1.9.2. Affective/Mood Disorders, Anxiety Disorders and Reaction Times towards Emotional Facial Expressions (EFE): The Literature Review
35
1.1.9.3. Other Psychopathological Disorders, Recognition Emotional Facial Expressions (EFE) and Reaction Times towards EFE: The
39
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Literature Review 1.2. Alcohol Dependence or Alcoholism 42 1.2.1. Ethyl Alcohol 42
1.2.2. Alcohol and Harm 43 1.2.3. Alcohol Dependence or Alcoholism 43 1.2.4. History of Classification 44 1.2.5. Current Diagnostic Classification 45 1.2.6. Epidemiology 47 1.2.7. Alcohol Dependence and Co-morbid Disorders 48 1.2.8. Alcohol Dependence and Cognition 49 1.2.9. Alcohol Dependence and Recognition of Emotional Facial Expressions (EFE): The Literature Review
50
1.3. Purposes of the Present Study 52 1.4. Hypotheses of the Present Study 53 2. METHOD 54 2.1. Participants 54 2.2. Materials 54 2.2.1. Demographic Information Form 55 2.2.2. CAGE Alcoholism Inventory 55 2.2.3. The Symptom Distress Checklist (SCL 90-R) 56 2.2.4. State- Trait Anxiety Inventory (STAI) 58 2.2.5. Beck Depression Inventory (BDI) 58 2.2.6. Emotion Recognition Test 59 2.3. Procedure 60 2.4. Data Analyses 60 3. RESULTS 63 3.1. Demographic Characteristics of Participants 63 3.2. CAGE Alcoholism Inventory, Beck Depression Inventory (BDI), State- Trait Anxiety Inventory, (STAI) and Symptom Checklist (SCL-90-R) Scores
65
3.3. Decoding Accuracy in General 67 3.3.1. Decoding Accuracy of Each Facial Expression 68 3.4. Manual Reaction/Recognition Times for Accurate Responses in General 71 3.4.1. Reaction Times for Accurate Responses towards Each Facial Expression
71
3.5. Covariates with Accuracy Decoding in General 73 3.5.1. Covariates with Decoding Accuracy in Each Facial Expression 74 3.6. Covariates with Manual Reaction Times for Accurate Responses 76 3.6.1. Covariates with Reaction Times for Accurate Responses toward Each Facial Expression
76
3.7. Misinterpretations of Emotional Facial Expressions 78 3.8. Stepwise Multivariate Regression 81 4. DISCUSSION 84 4.1. Alcohol Dependence and Co-morbid Disorders 84 4.2. Decoding Accuracy of Emotional Facial Expressions 85
xii
4.3. The Effects of Depression, State-Trait Anxiety, and Symptom Checklist on the Decoding Accuracy of Emotional Facial Expressions
87
4.4. Reaction Times for Accurate Responses toward Emotional Facial Expressions
89
4.5. The Effects of Depression, State-Trait Anxiety, and Symptom Checklist on the Reaction Times for Accurate Responses toward Emotional Facial Expressions
90
4.6. Misinterpretations of Emotional Facial Expressions 91 4.7. The Roles of BDI, STAI-S, SCL-90, Recognition of Disgust and Fear Emotional Expressions in the Prediction of Alcoholism
94
4.8. General Discussion and Conclusions 98 4.9. Limitations of the Present Study 100 4.10. Clinical Implications 102 4.11. Directions for Future Research 103 REFERENCES 105 APPENDICES 117 Appendix A: Demographical Information 117 Appendix B: CAGE Alcohol Use Inventory 118 Appendix C: Beck Depression Inventory (BDI) 119 Appendix D: State-Trait Anxiety Inventory (STAI) 122 Appendix E: The Symptom Checklist (SCL-90-R) 126 Appendix F: Basic Emotional Facial Expressions 130
xiii
LIST OF TABLES
Table 1 Demographic Variables 64 Table 2 Demographic Variables 64 Table 3 Descriptive Statistics of BDI, STAI, CAGE and SCL-90-R Results 66 Table 4 Descriptive Statistics of Subscales of SCL-90-R Results 67 Table 5 ANOVA Results of Recognition of Accuracy 68 Table 6 Descriptive Statistics of Accuracy Scores towards all Emotional
Expressions 68
Table 7 Descriptive Statistics of Accuracy Scores towards Negative Emotional Expressions
69
Table 8 Descriptive Statistics of Accuracy Scores towards the Expressions of Happiness, Surprise, and Neutral
70
Table 9 ANOVA Results of Happy Emotional Expressions 70 Table 10 ANOVA Results of Surprised Emotional Expressions 70 Table 11 ANOVA Results of Neutral Expressions 70 Table 12 ANOVA results of Reaction Times towards all Expressions 71 Table 13 Descriptive Statistics of Reaction Times towards Negative
Expressions 72
Table 14 ANOVA results of Reaction Times towards Happy Expressions 72 Table 15 ANOVA results of Reaction Times towards Surprised Expressions 73 Table 16 ANOVA results of Reaction Times towards Neutral Expressions 73 Table 17 Descriptive Statistics of Reaction Times towards the Expressions of
Happiness, Neutral and Surprise 73
Table 18 ANCOVA Results of Accuracy Decoding 74 Table 19 MANCOVA with Decoding Accuracy in Each Facial Expression 75 Table 20 MANCOVA with Reaction Times for Accurate Responses towards
Each Negative Facial Expressions 77
Table 21 Descriptive Statistics of Accurate Responses of All Participants towards All Emotional Expressions
80
Table 22 Variables in each step for Stepwise Multiple Regressions using Demographics, BDI, STAI, SCL-90, Facial Expressions and Reaction Times to predict Alcoholism Level
82
Table 23 Summary of Stepwise Multiple Regressions using demographics, BDI, STAI, SCL-90, Recognition of Facial Expressions due to predict alcohol dependence based on CAGE
83
xiv
LIST OF FIGURES
Figure 1. Episodes of Emotion. A spectrum of affective phenomena in terms of the time course
12
1
CHAPTER I
INTRODUCTION
In this chapter, firstly description, perspectives of emotion and emotional facial
expressions are explained. Then, inaccurate recognition of facial expressions in the
literature review is presented. Secondly, general information regarding alcohol
dependence and related literature review about impairment in decoding emotional facial
expression are mentioned. Finally, the purposes and the hypotheses of the present study
are explained.
1. 1. EMOTION
Generally, in Western culture, emotions are always seen as the enemies of
rationality. Mostly, they are considered as primitive or childish rather than mature or
civilized. Tears are stupid, tears are childish, and tears are sign of weakness. However,
as Ekman and Friesen says “… emotions are the most private, personal, and unique part
of ourselves. They are parts of ourselves that have enormous power over our lives”
(1975, p. 5). If emotions had not been existed, we would not have felt proud when our
loved ones do something worthy, we would not have experienced joy at the birth of our
children, anxiety when threatened, and grief at the loss of our loved ones (Lazarus,
1991, p. 3; Planalp, 1999, p. 10). Actually, without emotion, nothing makes any
difference, we become totally indifferent. They determine the quality of our lives.
1. 1. 1. Philosophical Background of Emotion
Emotions have always been central concern to human beings. Almost every
great philosopher from the periods of BC to contemporary ages had been concerned
with the nature of emotion and had theorized about its origins and expressions.
According to one of the well-known philosophers, Democritus (500 BC)
2
happiness or positive emotion was characterized by a state of mental and physical
equilibrium (Wikipedia, 2007). Similarly, Hippocrates, coeval of Democritus and
almost regarded as the founder of modern medicine, claimed that emotional states were
characterized by brain temperature, aridity, and moisture and he was the first
philosopher to establish a relationship between brain functioning and emotion. For
instance, according to him grief and anxiety arise from brain cooling, fear arises from
brain overheating (Wikipedia, 2007).
Plato (427-347 BC) was also one of the pioneers in proposing the interaction
between soul and body. He proposed a “Three State Theory.” These states were
Pleasure, Pain, and Neutral. Plato described pain as “the destruction of organic
harmony, pleasure as the recovery of this destruction, and neutral state as the harmony
itself” (Wikipedia, 2007).
However, according to Aristoteles (384-322 BC) who was a student of Plato,
pleasure was a normal state of a living and conscious being. Pain arose if any
obstruction occurred in this normal state. In other words, pain was the contrary of
nature. Clearly, Aristoteles distinguished emotional mental processes in three parts.
First one was potentialities of experiencing passions, capacities or predispositions;
second one was formed habits, namely repeated experience of Passions, disposition or
character; and third one was passions which are states accompanied by pain and
pleasure. According to Aristoteles, there were opposite feelings such as anger and
mercifulness, and love and fear. Additionally, in “rhetoric”, which is one of Aristoteles’
famous books, emotions were described as only biological products such as sneezing,
and they were contrary of thoughts and they affect the judgments (Oatley & Jenkins,
1996, p.12). In short, Aristoteles suggested that emotions had effects on cognition and
actually, they were based on our interpretation of events. Namely, Aristoteles
unwittingly claimed that emotions had cognitive roots.
In Patristic, Medieval, and Renaissance periods, emotion was a popular issue
among philosophers and literacy authors. Later, 17th century became more significant
than previous periods. For instance, Descartes, the founder of modern philosophy was
the first philosopher to propose the separation of mind and body. In his most well
3
known book “The Passions of the Soul”, he discussed the relationship between emotion
and neurophysiology. In addition, he claimed that there were six fundamental emotions,
which were love, hatred, sadness, joy, desire, and lastly wonder. And he discussed these
emotions in terms of neurophysiological dimensions (Oatley & Jenkins, 1996, p.15).
According to Descartes, emotions that were related to our physiological structure
resulted from soul, in which thinking takes place and he concluded that emotions could
be controlled by our thoughts. Moreover, Descartes agreed with Aristoteles’
assumptions that emotions rely on our evaluations of events. However, in his attempt to
improve upon Aristoteles and Thomas Aquinas, who saw emotion as experiencing and
evaluating stimuli in terms of their potential for gain and pleasure, Descartes’ research
led writers to confuse the mind-body problem with a soul-body problem (Candland et
al., 1977, p. 21).
Lastly, one of the most important 17th century philosophers Spinoza, who is
considered as a rationalist philosopher assumed that, the universe was a reflection of the
perfect God and human beings were a part of this great reflection. We human being,
God and this universe were all one. According to him, love was the main emotion;
however, there were other subsequent emotions such as envy, resentment, or passion
(Frijda, 1986, p. 265). Similar to Aristoteles, Spinoza seemed to have a cognitive view
toward emotions, as Spinoza also proposed that although emotion and idea had different
characteristics; emotion was determined by ideas (Deleuze, 2000, p. 12-20). Indeed,
more or less this vision constitutes a basis of cognitive approach.
1. 1. 2. Perspectives on Emotion
1. 1. 2. 1. Evolutionary Perspective and Charles Darwin
The evolutionary perspective on emotion derives from Charles Darwin the father
of modern biology. At the beginning of 20th century, in “the expression of the emotions
in man and animals”, that is one of the most important books of Darwin; he (1934)
stated that expressions of emotions were heritages from our past evolutionary habits.
Generally, emotions were derived from habits in which our evolutionary or individual
past had once been useful. However, some expressions of emotions still have served an
4
adaptive purpose. Darwin stressed their communicative function, animals including
humans, signal their readiness to fight, run, or attend to each other’s needs through a
variety of postural, facial, and other nonverbal communication. For instance, a baby’s
cry sends a signal to its parents, just as bared teeth display anger (Kowalski & Westen,
2005, p. 363). Additionally, “when infants feel hunger or discomfort or suffer, they
scream and in that case, their eyes are firmly closed so that their round skin becomes
wrinkled. The mouth is widely opened, with the lips retracted in a strange manner,
which makes it as a squarish form. The breath is inhaled inconsistently. This expression,
the firm closing eyelids and compression of the eyeball serve to protect the eyes from
becoming gorged with blood” (Darwin, 1934, p. 74). However, Darwin (1934) proposed
that some expressions of emotions did not have any function today, for example,
sneering is undeveloped remain of snarling that was functional in previous stage of
development of human beings (cited in Oatley & Jenkins, 1996, p. 2). Darwin gave
concrete examples such as weeping that indicates an extreme form of pain, as shown by
the writhing of the whole body and teeth clenching that are accompanied by sweating
and trembling (1934, p. 72).
Moreover, Darwin (1872) defined and arranged expressions of emotions based
on their original functions. He thought that emotions resembled reflex-like mechanisms
(cited in Oatley & Jenkins, 1996, p.2). He claimed that emotions were similar to reflex
actions that appeared due to the excitement of the peripheral nerve, which transmitted
its influence to certain neurons, and these transmissions, excited certain muscles or
glands to action. For example, coughing and sneezing were familiar instances of reflex
actions (Darwin, 1934, p.10).
According to Darwin, facial expressions of emotions were universal, not
learned, same in all cultures, biologically determined and occurred in many animal
species (1934, p.1; Ekman & Friesen, 1975, p.23; Stein & Oatley, 1992, p. 161). He
strongly emphasized the similarities between nonhuman and human. For instance,
animals also showed wonder, curiosity, imitation, attention, memory, and reasoning just
like human beings. Darwin (1934) concluded that facial expressions were important
tools for communication and recognition of emotions served a healthy relationship
5
between both humans and nonhumans (cited in Lazarus, 1991, p. 71).
1. 1. 2. 2. The Psychodynamic Perspective
Indeed, Sigmund Freud (1856-1939) the founder of classic psychoanalytic
theory did not directly propose a theory of emotion. He had little to say about the
structure of emotions. Instead, he emphasized determinable relationship between
perception and sensation (Candland et al., 1977, p. 62). His views on the nature of
emotions are complex and primarily on anxiety. Generally, he focused on emotional
traumas, inner conflicts, and personality. He considered emotions to be “archaic
discharge syndromes”. He thought that emotions are not always simple. Often they are
felt obscurely, some emotions and their meanings become clear only by expressing
them, or in talking them to another person or in reflecting upon them. In his famous
book on emotions “Inhibitions, symptoms and anxiety,” Freud formulated a new
conception of nature of anxiety that is considered as the result of an evaluation by the
ego of dangerous aspects of external or internal environment (Candland et al., 1977, p.
63).
Briefly, psychoanalysis has been primarily concerned with certain classes of
danger situations: birth, hunger, and absence of mother, loss of love, fear of castration,
fear of death, and fear of conscience. Namely, anxiety is not the result of repression that
is used in order to cope with dangerous situations, on the contrary, the reason for
repression (Candland et al., 1977, p. 193; Lazarus, 1991, p.235). According to
psychodynamic theorists, people can be unconscious of their own emotional experience,
that unconscious emotional processes can influence thought, behavior, or even health.
This perspective also suggests that we regularly delude ourselves about our own
abilities and attribute these abilities due to avoid unpleasant emotional consequences
(Kowalski & Westen, 2005, p. 360).
1. 1. 2. 3. Peripheral Perspective and James-Lange Theory of Emotion
Contemporary wisdom claims that William James’ great achievement was to
introduce psychology to American people. As a psychologist, one of his intellectual
6
achievements was to emphasize the peripheral component of the emotional experience,
an emphasis James made explicit in what has come to be called the James-Lange theory
of emotion over a century ago. In 1884, W. James proposed the first important
physiological theory of emotion. He suggested that bodily changes directly follow the
perception of an exciting “fact” and that “our feeling of the same changes as they occur
is the emotion”. In other words, James argued that emotion is rooted in the bodily
experience. According to him, first, we perceive the object then bodily response occurs
and lastly emotional arousal appears (Kowalski & Westen, 2005, p. 347). For instance,
when we see a stimulus such as a bear, we have a ponding heart, we begin to run and
than we fear. We do not run because of fear, we fear because of running. We feel sorry
because we cry, angry because we strike, afraid because we tremble (Candland et al.,
1977, p. 25). When his Danish colleague Carl Lange independently proposed a similar
view in 1885, since then this theory has been known as James-Lange theory of emotions
(Kowalski & Westen, 2005, p. 348). Lange proposed that vasomotor disturbances
following environmental events constitute emotional reactions, that the cognitive
qualities of emotion are secondary to the physiological qualities (Candland et al., 1977,
p. 87). According to Candland et al. although these two theories have obvious
differences, the two theoretical positions have historically been grouped together into
one theory (1977, p. 87).
In detail, James described two kinds of emotions, the coarser, and the subtler:
the former means that “one recognizes a strong organic reverberation”, the second one
is “those whose organic reverberation is less obvious and strong”. He implied an
acceptance of the evolutional nature of emotion: there are many emotions, they are
changeable, not stable, and they shade the coarser emotions into one another (Candland
et al., 1977, p. 24). Specifically, the subtle emotions are learned or acquired ones. For
example, resentment is learned through association with past events. However, the
coarser emotions are emotions that all human beings experience identically such as fear.
To sum up, the most influential writers on emotion were Aristoteles and
Descartes who were able to look toward the body and used physiological functioning of
the human beings. Continental theories from Descartes to James were primarily
7
centralistic, and they posited some form of a mind that based on the interpretation of
events, this interpretation provided us emotions or feelings. Undoubtedly, James
changed the emphasis from the central mind to periphery organs. Thanks to James, he
did not only make physiological researches but also he shifted attention from the central
mind to the peripheral structures of the body (Candland et al., 1977, p. 20).
1. 1. 2. 4. Central Perspective and Cannon-Bard Theory of Emotion
James-Lange theory of emotion could not be replicated and this theory met with
a great deal of criticism. Generally, these criticisms included the secondary position of
cognition when compared to physiology; it was questioned that the same environmental
stimulus did not elicit identical emotions in different people. Among these criticisms,
perhaps the most ardent one belong to Walter B. Cannon (1927-1931). Cannon
proposed an alternative theory suggesting that emotions are cognitive rather than
physiological state of arousal. He perceived the sequence of events as external
stimulation followed by neural processing followed by physiological reactions. Philip
Bard expanded Cannon’s theory by showing the thalamic structures for the expression
of emotion, this general theoretical position came to be referred to as the “Cannon-Bard
Theory”. This novel theory included that emotion-inducing stimuli simultaneously elicit
both an emotional experience, such as fear, and bodily responses such as sweating
(Candland et al., 1977, p. 87-88; Kowalski & Westen, 2005, p. 348). In the central view,
overt response follows upon brain activity that produces experience; response thus
follows upon experience. In other words, we run and tremble because we feel frightened
(Frijda, 1986, p. 177).
To conclude, indeed only certain aspects of James-Lange and Cannon-Bard
theories of emotion are opposite. The major point of disagreement between these
positions really concerns the point in time or in the sequence of events when
physiological functioning is an important concept in explaining emotions. James
stressed the importance of precognitive or determining physiological states, whereas
Cannon emphasized the importance of post-cognitive or response-type physiological
states (Candland et al., 1977, p. 88). In fact, these theories can be assumed as
8
complementary rather than opposites.
1. 1. 2. 5. Cognitive Perspectives
During the past decade, interest to the role of emotion in cognition and in
behavior has increased dramatically. In fact, it can be assumed that there have been two
approaches to the issues concerning cognition and emotion. The first was initiated by
Charles Darwin and was concerned with emotional expression and behavior. The
second approach was associated primarily with the work of William James. Indeed, both
Darwin’s and James’ writings indicated that they took for granted the assumption that
some kind of perception and evaluation must precede an emotional response (Candland
et al., 1977, p. 192). However, the relationship between cognition and emotion seemed
to be based on the 5th century, for instance Plato believed that reason must direct the
passions. Nowadays, contemporary theories are predominantly based on cognitive
principles to explain both the causes and consequences of emotions.
In terms of the nature of emotions, many cognitive theorists believe that emotion
depends on the interpretation or appraisal system. Appraisal can be defined as a kind of
personal meaning of an event, which includes the evaluations of the significance of the
facts for personal well-being (Leon & Hernandez, 1998). Similarly, Eich et al.
suggested that people have a perceptual-interpretive system that analyzes and evaluates
environmental stimuli for their emotional significance. This environmental stimulus is
interpreted based on cognitions and then the appropriate emotion arises (2000, p. 88).
First, the facts must be appraised for personal benefit and harm, and then an emotion
occurs. The way people respond emotionally depends on the appraisals they make, in
other words, their inferences about causes of the emotion and surely, their own bodily
sensations are crucial in emotional experience (Leon & Hernandez, 1998).
According to Stanley, Schachter and Jerome Singer (1962) (Schachter- Singer
theory) emotion involves two factors, first is the physiological arousal and second is the
cognitive interpretation of this arousal (cited in Kowalski & Westen, 2005, p. 361).
Specifically, when people experience a state of nonspecific physiological arousal, which
could be anger, happiness, or others, they attempt to figure out what these arousals
9
mean for their own sake. Meanwhile, although facial expressions are major source of
information about people’s emotions, knowledge about the situation can influence or
sometimes override information from the face (Kowalski & Westen, 2005, p. 362). In
order to interpret the arousal, people generally use situational cues. They respond as
what the situational cues suggest. Shortly, cognitive processes play a central role in
interpreting other people’s emotions. However, numerous studies support some degree
of Schachter-Singer theory. According to many cognitive theorists, people’s emotions
also reflect their judgments and appraisals of the situations or stimuli that confront them
not only their appraisal mechanisms (Kowalski & Westen, 2005, p. 361).
Specifically, in terms of the antecedents of emotions, basic emotions are
typically caused by the perceptions of general categories of events: happiness arises
with a perception of the progress towards a goal; sadness arises when a goal is lost or
when major loss of an anticipated pleasure; anger occurs when a plan is blocked;
perceived threats to one’s body and self-esteem leads to anxiety; a goal conflict or a
threat to self-preservation leads to fear; a perception of something to reject leads to
disgust; and desire is produced by a perception of something to approach and so on.
These emotion production rules are also central to various appraisal theories of emotion
(Eich et al., 2000, p. 88; Stein & Oatley, 1992, p. 209).
Some cognitive theorists prefer to explain emotion profoundly as a process that
includes five basic components; first is objects or precipitating events, second is
appraisal, third is physiological changes, fourth is action or expression, and final
component is regulation (Planalp, 1999, p. 11). According to their point of view, this
process begins with a precipitating event. It seems better to explain process theories of
emotion by giving a specific example on sadness. For instance, sadness is generally felt
when an undesirable event happens, such as loss of loved one or separation or being
rejected. Surely in order to generate sadness, this event must be appraised not only as
negative but also as feeling of weakness. Otherwise anger or fear can be felt. And
physiologically one can be tired, has low in energy. In action stage, withdrawing from
social contact or talking less cause sadness, regulation stage includes talking to someone
closer about sad feelings or events, or trying to act happily (Planalp, 1999, p. 12).
10
To sum up, there are many perspectives and theories about the nature or causes
of emotions. Some has been able to replicated; some has been rearranged based on
contemporary findings.
1. 1. 3. Emotion and Related Concepts: Feeling, Affect, Emotional States, Mood,
and Emotional Disorders
The phenomena to which the label “emotion” or “emotional” is a difficult
matter, also there has not been an agreement due to distinguish them. For example,
some people consider hunger as an emotion; others do not (Frijda, 1986, p. 1). For this
reason, to begin with, it is very important to define some terms.
Literally, the word emotion and its derivates have passed through identifiable
stages. In 17th and18th centuries, written language remained faithful to the Latin
derivation of emotion, namely, emovere “to move away from”.
Emotion refers to in:
1695: a moving out, a migration
1735: causing movement
1822: a physical moving, stirring, or agitation
The application of the word to mental states developed simultaneously:
1660: a vehement or excited mental state
1735: tending or able to excite emotion
1808: a mental feeling or affection (for example, of pain, desire, hope)
1847: connected with the feelings or passions (Candland et al., 1977, p. 4).
By the late 19th century, it was accepted to distinguish emotion from cognition
(reasoning) and volition (willing). This separation still continues. Emotion is commonly
thought to be a separate faculty, but it interferes with rational aspects of our minds, and
subverts or distorts our motivation or values. In sum, neither common usage nor the
definitions offered by theorists clarify the problem of defining emotion because the
meanings of the term continue to evolve.
To begin with, emotion can be defined as an internal reaction of feeling, which
11
may be either positive (such as joy) or negative (such as anger), and may reflect a
readiness for action (Vasta, Haith & Miller, 2000, p. 448).
According to Oatley and Jenkins, emotion is generally caused by a person
consciously and unconsciously evaluating an event as relevant to a goal that is
important; the emotion is felt as positive when a goal is reached, as negative when a
goal is obstructed. Another definition of these authors is that, “an emotion is usually
experienced as a distinctive type of mental state, and sometimes is accompanied or
followed by bodily changes, expressions and actions” (1996, p. 96). On the other hand,
Eich and et al. stated that “an emotion has properties of a reaction: it often has an
identifiable cause such as a stimulus or antecedent thought, intense experience of short
duration, emotions usually have high cognitive involvement and the person is aware of
them” (2000, p. 89).
Probably, the most comprehensive definition belongs to Ekman who defines
emotion as a whole process, “a particular kind of automatic appraisal is influenced by
our evolutionary and personal past, and then a set of physiological changes and
emotional behaviors begin to deal with the situation”. Usually, they occur in a response
to a social event that can be real, remembered, or imagined (Ekman, 1993). Surely
words are important in terms of defining and dealing with our emotions however, as
Ekman says “emotions are not so simple to reduce into words” (2003, p. 13).
In general, many terms are used to illustrate emotion such as mood, affect, and
feeling, which are generally used interchangeably; however, there are some distinctions
between these terms. Contemporary American and English oral usage often
differentiates these terms: for instance, primarily emotion is used to refer to observable
behavior, and feelings to inferred states. Thus, emotion is assumed as intense but
temporary, and feelings as weak but more permanent (Candland et al., 1977, p. 4). On
the other hand, Lazarus defines feeling as a sensory perception, such as feelings of pain,
pleasure, and distaste, rather than as emotion (1991, p. 57). Indeed, in many studies, the
term “feeling” is used as the synonym of emotion.
The term affect is more general term is used any phenomena related with
emotion such as moods and disposition or both (Eich et al., 2000, p. 89). Lazarus
12
defines affect as subjective quality of an emotional experience (1991, p. 57).
Alternatively, Vasta et al. define affect as the outward expression of emotions through
facial expressions, gestures, and innotation etc (2000, p. 448). In addition, the terms
“emotion” and “emotional episode” are used for states that endure a limited amount of
time (see, Figure 1).
Figure 1. Episodes of Emotion . (A spectrum of affective phenomena in terms of the time course, Oatley & Jenkins, 1996, p.124).
-Expressions-
-Autonomic
Changes-
__Self-reported
Emotions____
____Moods___
____Emotional disorders___
___Personality traits__
Seconds Minutes Hours Days Weeks Months Years Lifetime
One of the important concepts that is often confused with emotion is mood.
Actually, mood differs from emotion in that the feelings or emotions involved last over
a longer period (Ekman & Friesen, 1975, p.12). Moods have a tendency to be diffuse
rather than directed toward individuals, events, or objects in the environment. Yet
moods have dramatic effects on our behavior, they affect the intensity of our reactions
to emotion and provoke stimuli (Canland et al., 1977, p. 108). According to Eich et al.
mood tends to be more subtle, longer lasting, less intense and nonspecific compared to
emotions. In contrast, people may not be aware of their mood (2000, p. 89). For
instance, a feeling of anger lasting for just a few minutes, or even for an hour, is called
13
an emotion. However, if the person remains angry all day or becomes angry for days,
then it is called mood (Ekman & Friesen, 1975, p.12). On the other hand, Oatley &
Jenkins (1996) define moods as an emotional state that endures for hours, days and
sometimes weeks and generally, they do not have any intention. However, emotions
have an intention or have an object. The best way to discriminate mood and emotion is
that, emotion tends to change more easily than mood, which is more resistant to change
(p. 125). Despite these differences, apparently, it is not easy to discriminate mood and
emotion.
If emotional states last longer than moods, then this state is called as emotional
disorders that refer to mood disorders on the basis of currently used classification
system DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, APA, 1994).
One step ahead from emotional disorders is called as personality disorders which last a
lifetime (Oatley & Jenkins, 1996, p. 127). It is found that people with personality
disorders have more emotional intensity than others do (Linehan, 1987). Therefore,
people can differ in terms of subjective experience of emotion that refers to what the
emotion feels like to the individual. For example, when we have a blue mood, we feel
sadness for hours or days; a melancholic personality is prone to feeling sad; depression
is the mental disorder in which sadness and agony are central (Ekman, 2003, p. 93).
For instance, in terms of subjective experience, one of the most prominent
psychological disorders is Alexithymia refers to difficulty in distinguishing emotions
(Helmers & Mente, 1999). Literally, “A-lexi-thymia” means “without language for
emotions” (Westen, 1999). In other words, alexithymic individuals have difficulty
telling their emotions; mostly it is believed that they misinterpret their emotional arousal
as symptoms of physical illness (Helmers & Mente, 1999).
1. 1. 4. Emotional Facial Expressions (EFE)
Human emotions are the language of human social life. They provide the outline
patterns that relate people each other. For instance, the smile; the best-established
universal signal of emotion, happiness is the emotion of cooperation; anger is the
emotion of interpersonal conflict (Oatley & Jenkins, 1996, p.87). According to Oatley
14
and Jenkins, “emotions are heuristics”. Emotional states organize ready repertoires of
action. In other words, they occur without our need to say to ourselves, “this situation is
dangerous”, instead we simply feel frightened and we take action (1996, p. 258).
Specifically, facial expressions are the readouts of these internal emotional states
(Lazarus, 1991, p. 70).
Actually, emotional facial expression (EFE) refers to the overt behavioral signs
of emotion or it indicates something within that is externalized (Oatley & Jenkins, 1996,
p.124). In detailed, emotional facial expressions can be defined as a means of
communication that are more rapid than language and they facilitate communication in
everyday life in order to interpret the intentions, goals, opinions and attitudes of others
(Erickson & Schulkin, 2003; Batty & Taylor, 2003).
In daily life, generally, we monitor the emotional reactions of others and prefer
reacting and regulating our behaviors based on them. Thus, they constitute very
powerful tools in social coordination (Batty & Taylor, 2003). According to Erickson &
Schulkin (2003) “as human beings, we construct and interpret the world around us into
useful and understandable categories in order to predict and understand events central to
human survival and experience”. Similarly, Ekman postulated that emotional
expressions were crucial to the development and regulation of interpersonal
relationships (1992, p. 177).
Surely, when interpreting facial expressions of others, we consider the
situational and social settings in which expression is produced. Our main tool for
reading expressions is usually a “face”. It is assumed that emotions are often revealed
on the face that can display more than ten thousand expressions (Ekman, 2003, p. 14;
Ekman, 1993; Lazarus, 1991, p. 70). Kowalski & Westen support Ekman that, face is
the primary center of emotion (2005, p.351). The face is not only a means of
communicating emotions, but also is a vehicle to communicate intentions (...) (Erickson
& Schulkin, 2003). Face is a very important source of social information and it appears
as if we are biologically prepared to perceive and respond to faces in a universal manner
(Eastwood & Smilek, 2005). Also, it is known that specific signals in each part of the
face that convey the messages of fear, surprise, sadness, happiness or enjoyment, anger,
15
disgust, and combinations of these emotions (Ekman & Friesen, 1975, p.14). Even
though, some people believe that they can read attitudes, personality, moral character,
and intelligence from face, it is certain that sex, age and ethnicity may be read more
accurately and easily than all above (Ekman & Friesen, 1975, p.13). More specifically, a
person is most easily identified by his face than his body. For instance, when we are told
a person that we have not met yet, usually we want to see the photograph of his face.
According to Ekman and Friesen, problems in understanding facial expressions arise
because most of the time people do not watch each other’s faces (1975, p.13). In fact,
watching someone’s face is intimate, thereby, we generally do not want to be intrusive
or rude by starring at people’s faces.
Ekman and Friesen pointed out that some facial expressions are extremely rapid,
brief, and lasts merely a fraction of a second. These are called micro-expressions. It is
rare for a facial expression of emotion to last as long as five or ten seconds, very long
facial expressions are not genuine expressions, these exaggerated form of the
expressions are called as mock expressions (1975, p.14; Ekman, 1993).
Due to test their assumptions, Ekman and Friesen constructed Facial Atlas of the
face, which is aimed to portray photographically each of the universal facial expressions
of emotion. For this, they first constructed a table which all the facial muscles and six
emotions including famous theorists such as Darwin, Duchenne, Huber and Plutchik
and their proposals about the relationship between emotion and muscles. And they filled
the gaps based on their deep experiences. Then, they took of photos of the models and
each of the facial areas (brow/forehead; the eyes/lids, and the root of the nose, and the
lower face including the cheeks, mouth, most of the nose, and chin). In conclusion, the
completed Atlas consists of series of photographs of the three different areas of the face,
each photograph keyed to one of the six emotions (Ekman, 1993).
1. 1. 5. Basic or Discrete Emotions
According to Frijda, emotions can be characterized in terms of action readiness
mode corresponds to what are often called “primary”, “elementary”, “basic” or
“fundamental” emotions. For instance, anger is the urge to attack or urge to regain
16
freedom of action and control. Fear is the urge to separate oneself from aversive events
(1977, p. 72). On the other hand, Lazarus claimed that primary or basic emotions
express universal biological rules handed down genetically through evolution because
they have proved adaptionally useful (1991, p. 70).
Ekman postulated that each of the emotions is not a single affective state but a
“family” of related states. Each member of an emotion family shares a certain
characteristics, such as commonalities in expression, in physiological activity, in nature
of the antecedent events and appraisal processes. And these shared characteristics are
the products of our evolution. According to him basic emotions arise from an inherited
neural structure, involve a characteristic neuromuscular response pattern, and are
correlated with distinctive subjective qualities for each emotion. He distinguished basic
emotions from one another and from other affective states, such as moods, emotional
traits, etc. on the basis of these criteria (1992, p. 173-175).
Recently, there are six universally accepted basic emotions; fear, surprise,
sadness, happiness, anger, disgust. Each emotion has its own characteristics and
appearance figures. In fact, Ekman (1993) emphasized that, there is no single expression
for each emotion. For instance, there are 60 anger expression variations in intensity
stretching from annoyance to rage. These emotion families distinguish from the family
of other expressions.
Furthermore, there are other emotions such as love, jealousy, hatred, envy,
regret, interest, guilt or despair that are spoken in some societies but not in others. The
elaborations or combinations of these basic emotions are called as social emotions
(Stein & Oatley, 1992, p. 162). These social emotions are not primarily of survival or
biologically based but very critical for social interaction of individuals. For instance,
pride has been proposed to be a combination of joy and anger; love a combination of joy
and acceptance; envy or hatred arise from a comparison of oneself with another person
(Stein & Oatley, 1992, p. 209; Oatley & Jenkins, 1996, p. 88). Indeed, as Stein and
Oatley emphasized that it is more common to experience the mixed feelings instead of
single ones in almost all cultures (1992, p. 209).
17
1. 1. 5. 1. Basic or Discrete Emotions: Definitions
Basic emotions are distinguished as negative and positive. Happiness is a
positive emotion. Fear, anger, disgust, and sadness are negative emotions and most
people do not enjoy them. Surprise is neither positive nor negative (Ekman & Friesen,
1975, p. 99). Ekman (1992b) stated that all negative emotions differ in their appraisal,
antecedent events, behavioral responses, physiology, and other characteristics.
Generally, people strive to attain emotions if pleasant, to avoid them if unpleasant (Stein
& Oatley, 1992, p. 203). People differ in whether they can enjoy, tolerate of surprise,
fear, disgust, happiness, anger, or sadness. No one feels emotions in the same way.
People also differ tremendously in experiencing the emotional intensity. For instance,
the extent to which people experience happiness is relatively stable across age and
gender but differs substantially across cultures. More specifically, cultural traditions and
upbringing within a culture play a role in shaping one’s attitude about feeling or
displaying emotions.
1. 1. 5. 1. a. Happiness
Happiness is the emotion that most people want to experience. People like being
happy. It makes feel good. People choose conditions in which happiness are
experienced and almost organize their lives based on feeling good. Oatley and Jenkins
defined happiness as the emotion or mood of achieving subgoals and of being engaged
in that one is doing (1996, p. 259). It is observed that when people are happy, they are
more cooperative and altruistic (Oatley & Jenkins, 1996, p. 87).
In English, happiness is used almost synonymous with the pleasure and
excitement. Pleasure is defined as a product of positive physical sensations that is
opposite of the physical sensation of pain. Usually people feel happy when they
experience pleasurable sensations, unless they get punishment for these feelings or feel
guilty about them. Excitement is defined as the opposite of boredom. People become
easily excited when something arouses their interests. However, in boredom nothing is
new and attracts attention you. Certainly, people can feel happy without excitement or it
18
is also possible to be excited without happiness. Instead of happiness, excitement can
blend with fear or anger (Ekman & Friesen, 1975, p. 100). Briefly, excitement and
pleasure are different experiences, which often involve happiness. Therefore, it seems
that there are four routes of happiness; pleasure-happiness, excitement-happiness, relief-
happiness or happiness involving self-concept. When pain stops, people get happy.
When people do not feel negative emotions such as fear, anger, or disgust, commonly
they feel happy. This kind of happiness is the relief-happiness. Fourth kind of happiness
is about self-concept. Something, which enhances your view of yourself happens, this
situation affirms or further elaborates a favorable self-concept. Praise, friendship, the
esteem of others is rewarding and makes you feel happy. This kind of happiness
originally is developed from experiences in which people get approval. It is a more
contented, smiling happiness, rather than laughing.
Happiness varies not only in type, but also in intensity. It can vary from a smile
to a broad grin, in the extreme form, laughter with tears. Surely, the presence of laughter
does not always indicate the intensity of the happiness. People can extremely feel happy
and may not laugh. Smiles that are a part of the happiness facial expression often occur
when a person is not happy. People can smile in order to mask their emotions.
Happiness is exhibited in the lower face and lower eyelids. The intensity of a
happy expression is primarily determined by the lip position. The mouth may or may
not be parted, with teeth exposed or not. Additionally, a happy person shows wrinkle
lines running from the nose out and down to the area beyond the corners of the mouth.
These naso-labial folds occur. In addition, the cheek becomes raised when there is a
pronounced smile or grin. The more extreme the smile or grin, the more pronounced
will be the naso-labial folds, the raising of the cheek, the crow's feet, and the lines under
the eyes (Ekman & Friesen, 1975, p. 110).
Happiness often blends with surprise, which is the shortest emotion. This blend
lasts only for a moment. Happiness also blends with contempt, producing a smug,
scornful, or superior expression. Additionally, it can blend with anger. Most commonly,
a smile or slight grin is used to mask anger, in which case the person looks happy, not
angry. Interestingly, a person can feel both happy and angry at the same time, enjoying
19
his/her anger. Lastly, happiness blends with fear. Indeed, the expression is not a blend,
but either a comment or a mask. It can be felt at the same time for instance in a roller
coaster. Happy- sad emotions can also blend. This kind of expressions generally occurs
in bittersweet experiences or when the happy expression is being used as a mask-
laughing on the outside, crying inside (Ekman & Friesen, 1975, p. 112).
1. 1. 5. 1. b. Sadness
There are many words to describe sad feelings: distraught, disappointed,
dejected, blue, depressed, despairing, grieved, helpless, miserable, and sorrowful.
According to Oatley and Jenkins, sadness is the opposite of happiness. It can be
described simply as the emotion of losing a goal or social role (1996, p. 259).
Specifically, anything can make you sad, but the most often you are sad about losses.
Many types of loss can trigger sadness. For instance; loss through death or rejection by
a loved one or loss of an opportunity or reward through your own effort, or another's
disregard. As compared with fear that looks toward future, sadness seems to look
toward the past (Oatley & Jenkins, 1996, p. 260; Ekman, 2003, p. 83; Ekman & Friesen,
1975, p. 114).
Ekman distinguished sadness from agony. According to him, in sadness there is
more resignation and hopelessness whereas in agony there is a protest. Therefore, agony
attempts to deal actively with the source of the loss, it seems to include rebellion.
However, sadness in which suffering is muted is a passive feeling. People silently
endure their distress. This suffer is not like physical pain; it is the suffering of loss,
disappointment, or hopelessness. Thus, sadness is rarely a brief feeling. It is one of the
long-lasting emotions. People are usually for at least minutes and more typically for
hours or even days (2003, p. 84).
Even in such intense grief, there are moments when other emotions may be felt.
For instance, we feel angry toward the person who is responsible for a loss, while we
feel sadness and agony about the loss itself (Ekman, 2003, p. 85; Ekman & Friesen,
1975, p. 114). Or grieving person may feel fear in terms of how s/he will survive
without her/his loss. Moreover, when recalling some funny moments with the deceased,
20
amusement can be felt.
There is a distinctive appearance in each of the three facial areas during sadness.
The inner corners of the eyebrows are drawn up and the inner corner of the upper eyelid
is raised, and the corners of the lips are down.
Sadness blends with fear and anger mostly. Blends of sadness with disgust and
blends of sadness with happiness are also common types.
1. 1. 5. 1. c. Fear
Fear is the emotion of anticipated danger (Oatley & Jenkins, 1996, p.260). In
other words, the antecedent event for fear is physical or psychological harm (Ekman,
1992, p. 184). Survival depends on learning to avoid or escape from situations that
cause severe pain and the physical injury (Ekman & Friesen, 1975, p. 47). Namely, fear
renders a mode of readiness to cope with danger. Thus, it promotes vigilance for the
feared event that can be an imagined or real. Even though fear is accepted as unpleasant,
it has function to protect the body from further injury (Oatley & Jenkins, 1996, p.260).
According to Darwin, fear is the most depressing of all the emotions, it lowers the
temperature, induces utter, and might be associated with the most violent and prolonged
attempts to escape from the danger. Nevertheless, extreme fear often acts as a powerful
stimulant (1934, p.32).
Fear differs from surprise in three ways. Firstly, fear is a horrible experience,
surprise is not and fear is unpleasant, moreover can be traumatic, but surprise can be
pleasant or unpleasant. Secondly, you can be afraid of something familiar that you know
very well is going to happen. For example, although it is not surprised for you to go to
the dentist, you can still be frightened. Thirdly, in terms of duration, surprise has always
a short duration, but fear can also occur gradually (Ekman & Friesen, 1975, p. 48-49).
Even danger disappears; you may still feel fear depending upon your appraisal of the
feared situation.
Just like surprise, fear may be followed by any of the other emotions or by no
emotion at all. You may become angry or disgusted or sad or even happy if threat has
been avoided (Ekman & Friesen, 1975, p. 50). Nevertheless, the most common blend
21
with fear is surprise. Because usually fearful events are unexpected and it is common to
be both surprised and frightened at the same moment or nearly at the same moment.
The appearance of full-face fear is characterized as; the eyebrows are raised and
drawn together, the eyes are open, and the lower lid is tensed, and the lips are stretched
back unlike in surprise expression (Ekman & Friesen, 1975, p. 50). Actually, there are
two-way fear expressions; each of these expressions has a slightly different meaning.
One is apprehensive fear that refers to an impending a harmful event. In this expression,
fear is shown only in brow and eyes, not in lower face (mouth), another is frozen or
horrified fear. Unlike apprehensive fear, the expression of horrible fear does not include
a brow component. Mouth is more stretched (Ekman & Friesen, 1975, p. 55-60).
According to Frijda who considered fear as a protective response, extreme fear is
expressionless (1986, p. 18).
On the other hand, Frijda describes the fear expression as “forceful eye closure,
frowning by drawning the eyebrows together, bending the head, hunching the shoulders,
bending the trunk, and knees” (1986, p. 16).
1. 1. 5. 1. d. Anger
Ekman and Friesen claimed that anger is very likely the most dangerous
emotion. When people are angry, they hurt others purposefully (1975, p. 76). However,
according to Lazarus, although anger is commonly classified as negative emotion,
people often report feeling good about their anger. Nevertheless, he added that when
anger is acted out, it can have harmful social or physiological consequences, especially
when it is not managed (1991, p. 5).
Oatley & Jenkins defined anger as asserting ourselves in dominance. In other
words, according to them, it is the emotion of frustration with anything we are trying to
do, or with anyone who shows lack of consideration or who obstructs us (1996, p. 260).
They confirmed the frustration-aggression hypothesis of Berkowitz (1989) including
that aggressive behavior arises from frustrated needs or desires. The frustrating obstacle
may not be a person, you can be angry at an object or natural event that frustrates you,
even though you may feel a bit embarrassed or less justified in your anger (Ekman &
22
Friesen, 1975, p. 79). Surely, your anger will be more likely and more intense if you
believe that the agent of the interference acted arbitrarily. As a result of this feeling, you
may express your anger directly, indirectly, symbolically or displacing it onto a safer or
more convenient target, such as a scapegoat.
Beside frustration, a second major provocation to anger is a physical threat.
However, you may feel fear if the threatening injury is much more powerful than you
are, if this injury is insignificant or unable to hurt then you feel more contempt.
Third major source of anger is someone’s action or statement that causes you to
feel psychologically rather than physically hurt, such as a rejection, an insult.
Doubtlessly, the more you care the person that rejects you, the more you get angry. An
insult from someone you have little regard for, a rejection by someone, whom you never
consider as a friend or lover, may make you feel contempt or surprise rather than anger.
On the other hand, if hurt comes from the person you care greatly about, you may feel
sadness instead of anger or both. This type of source, at the same time may cause you to
rationalize this anger feeling and make you feel guilty.
Fourth major source of anger is someone’s action or statement toward you or
someone that violate your moral values. If someone treats another person in a manner
you consider immoral you may become angry even though you are not directly affected.
For instance, sexual or physical abuse or anything that is opposite to your values,
clearly, if you have a value about marriage like “until death us a part” when a husband
leaves his wife, this situation may lead to anger you.
Absolutely, there are other sources of anger, such as a person’s failure to meet
the expectations, and another person’s anger are two of the causes of anger.
Anger varies in intensity from slight irritation or annoyance to rage or fury.
People differ not only in terms of what makes them angry or in terms of what they do
when they are angry but also in terms of how long it takes them to become angry
(Ekman & Friesen, 1975, p. 81).
Also, boys and girls differ in showing anger, girls are taught to control or not to
show anger toward anyone but boys are encouraged to express their anger (Ekman &
Friesen, 1975, p. 76).
23
Similar to other emotions, anger also blends with other emotions; a person may
also feel anger-sadness, anger-fear, and anger-disgust at the same time. Some people
even like being angry. They enjoy argument. Moreover, intimacy can be established or
reestablished by an angry exchange between two people.
Human anger has a large variety of manifestations especially is manifested in
each of the three areas; the eyebrows are lowered, and drawn together, the eyelids are
tensed, and the eye appears to stare in a hard fashion. The lips are either tightly pressed
together or opened in a square. Actually, the nostrils may be widened, but this is not
essential to the anger facial expression and also may occur in sadness (Ekman &
Friesen, 1975, p. 76; Frijda, 1986, p. 19).
Generally, the blended expressions are accomplished by two blended emotions
registering in different areas of the face. However, with anger unless the expression is
registered in all three areas of the face, the message becomes ambiguous. Anger
message is overwhelmed by the other emotion in blend. In other words, anger is easily
masked except two expressions in which anger message remains salient. One is anger-
disgust blend expression. The other is the blend need not require different facial areas
show the different emotions. There are other blends in which the blending is
accomplished by separate facial areas rather than mixing within facial areas, contempt-
anger blend, anger-surprise blend, happiness-anger blend, and sadness-anger blend
(Ekman & Friesen, 1975, p. 92-94). One of the most common mixtures is sadness and
anger, which may be caused by a loss that also frustrates some plan (Stein & Oatley,
1992, p. 209).
1. 1. 5. 1. e. Surprise
Ekman and Friesen indicated that surprise is the most brief emotion (1975, p.
34). It is sudden. If you have a time to think about that event, you will not feel surprised.
Also, it does not take long time unless the surprising event unfolds new surprising
elements. Correspondingly, Frijda defined surprise as a response to sudden stimuli that
consists of widening of the eyes, brief suspension of breathing, and general loss of
muscle tone. The loss of muscle tone causes the mouth to fall open, and may make the
24
subject stagger or force him to sit down (1986, p. 18). The more unexpected event, the
greater the surprise you feel (Teigen & Keren, 2002). Specifically, Ekman and Friesen
postulated that surprise is triggered by both unexpected and misexpected events.
Unexpected events can be defined as an unusual event, which is unanticipated. At that
moment, the surprised person does not expect anything in particular to happen. In
misexpected surprise, there is an aroused specific anticipation for something different to
happen at that moment. In this situation the event needs to be usual but unexpected for
surprising (1975, p. 34).
Almost anything can be surprising; a sight, smell, taste, touch and surely, the
greater the unexpected thing, the more surprised you will be. In other words, surprise
has different intensity levels from mild to extreme, depending upon the event itself.
Because of the brevity of the experience of surprise, another emotion quickly follows it,
the face generally shows a blend of surprise, and subsequent emotion depending upon
how you feel about what surprised you. Therefore, surprise may turn to pleasure or
happiness, or disgust, or aggression, or fear depending on the event. Ekman (1992)
states that fear is the most common subsequent emotion to surprise, because unexpected
events are usually dangerous, and mostly people associate surprise with fear. While
some people seek novelty, love being surprised, and organize their lives, moreover
some people cannot stand being surprised (Ekman & Friesen, 1975, p. 36).
The appearance of full-face surprise is characterized as; the curved and high
eyebrows, stretched skin below the brow, opened eyelids, and opened mouth with
parted lips and teeth, dropped jaw. The mouth may be just slightly open, moderately
open or widely open depending upon the intensity level of surprise (Ekman & Friesen,
1975, p. 39-40).
There are four types of surprise; first is questioning or uncertain surprise
includes only the eyes and brow movements of the full-face surprise expression. Second
is astonished or amazed surprise that is characterized only the eyes and mouth
movements. Third is dazed surprise or less interested surprise. Dazed surprise occurs
when only the brow and mouth movements appear. The last type is the combination of
these three facial areas. Its message is clear that is surprise (Ekman & Friesen, 1975, p.
25
43).
1. 1. 5. 1. f. Disgust
Disgust is a feeling of aversion. Specifically, disgust is the emotion of revulsion
and avoidance of anything that makes one sick (Ekman & Friesen, 1975, p. 66). People
can feel disgust from any taste, a smell, a sight, a touch or a sound or even an idea.
According to Oatley and Jenkins, disgust may be an innate rejection of substances
because they are decayed, infectious, or toxic (1996, p.262). However, Ekman and
Friesen argued that what is repulsive to one culture might be attractive to another
culture. Because, culture usually expresses itself in eating habits as well. For instance, a
popular food can be an aversive food in other cultures.
Disgust usually involves getting-rid-of and getting-away-from responses.
Removing the object or oneself from that object is a goal. Generally, nausea and
vomiting accompany with disgust. Nausea and vomiting occur without disgust and
likewise disgust occurs without nausea or vomiting (Ekman & Friesen, 1975, p. 66).
Disgust can blend with surprise, fear, happiness and also with sadness but mostly
disgust blends with anger. The appearance of full-face disgust is characterized as; the
upper lid is raised, the lower lip is raised and pushed up to the upper lip, or is lowered
and the nose is wrinkled, the cheeks are raised, lines show below the lower lid is pushed
up but not tense, the brow is lowered, lowering the upper lid (Ekman & Friesen, 1975,
p. 76).
1. 1. 6. Universality of Emotional Facial Expressions (EFE)
Are facial expressions of emotion the same for people everywhere? Are they all
cultural products? Are facial expressions universal or specific to each culture?
Alternatively, are facial expressions an accurate reflection of emotional experience?
These questions have played a central role in many studies.
In fact, the innateness of an expression was one of the widespread questions that
Darwin had curiosity. In 1872, Darwin sent questionnaires to 36 observers inquiring the
way of expressions of emotions such as astonishment by eyes and mouth being opened
26
widely etc. As a result of this survey, he found impressive agreement among observers
(Frijda, 1986, p. 67). Definitely, even though this survey had many methodological
problems, it gave considerable strength to the global conclusion, which has been
confirmed by recent studies.
In terms of universality of expressions of emotions, especially Izard in 1969 and
1971, Ekman and his colleagues in 1972 and 1982 made major studies concerning
Western, Japan and African cultures.
As a result of these major studies, Paul Ekman in 1972 proposed a Two-factor
theories of emotion (one factor is universal/biological, other is cultural) or
Neurocultural theory that refers to an innate neural patterning of expressions is
accompanied by culturally variable display rules that regulate when each expression can
be made. Ekman and his colleague Wallece V. Friesen (1975) postulated that six basic
emotional categories are universally recognized. Namely, these are; happiness, sadness,
surprise, anger, fear, and disgust (Oatley & Jenkins, 1996, p. 67; Abboud, Davoine, &
Dang, 2004). However, Izard (1977) adds interest, shame, guilt, and contempt to this list
of universal expressions (cited in Frijda, 1986, p. 68). Yet, there has not been
confirming studies of Izard’s list of emotions.
Briefly, in a study of Ekman and his colleagues, they displayed to the
participants some photographs, which include the faces of North American actors that
express fear, anger, happiness, surprise, disgust, sadness. Different cultural groups,
ranging from Swedes and Kenyans to the members of a preliterate tribe in New Guinea
(Ifaluk tribe) with minimal Western contact, participated to this study. Consequently,
results revealed that all groups recognized six emotions correctly. Then these emotions
have been accepted as universal (Ekman & Friesen, 1975, p. 23). Shame and excitement
or interest may be considered as universal but they have not been firmly established yet
(Ekman & Friesen, 1975, p. 22; Westen, 1999, p. 489). On the other hand, Lewis &
Haviland-Jones (2000, p. 239) mentioned that the literature recently focuses on seven
emotions: happiness, fear, sadness, disgust, anger, surprise, and nowadays contempt.
Contempt is defined as the emotion of interpersonal rejection especially toward
members of out-groups (Oatley & Jenkins, 1996, p. 262). With regard to Lewis &
27
Haviland-Jones, Ekman stated that contempt facial expression which is expressed as a
variation on the closed-lips disgust mouth were not included in preliterate culture
studies (1992, p. 176). Therefore, contempt can not be assumed as one of the basic
emotions. Because, the universal feature of basic emotions is based on the appearance
of the face for each of the primary emotions. To conclude, there are still debates on the
universality of contempt emotion.
Furthermore, it was found that all facial expressions could vary from one culture
to another. People in different cultures may change in what they have been taught about
managing or controlling their facial expressions of emotions or display rules (Ekman &
Friesen, 1975, p.24; Malatesta and Haviland, 1982). People learn to control the way
they express many emotions by using different patterns of emotional expression that are
considered appropriate within their cultures. For instance, in another study of Ekman
and Friesen (1975), findings revealed that, although Japanese and Americans had
virtually identical facial expressions, in terms of display rules Japanese masked their
facial expressions of unpleasant emotions more than Americans did (p. 24).
Corresponding to this study, another study proved that the same facial expressions were
judged as showing the same emotions in all the countries like US, Japan, Chile,
Argentina, and Brazil regardless of language or culture (Ekman & Friesen, 1975, p. 24).
Shortly, people in two different cultures may feel sadness at the death of a loved
one, however, one culture may prescribe that they mask their facial expression with a
mildly happy appearance. More specifically, if a language does not have any words for
describing an emotion, it does not mean that emotion does not occur in this culture. For
example, Ekman (1993) argued that although the Tahitians have no word for describing
sadness, sad expressions were observed in Tahitian people who had experienced a loss.
In sum, emotions and emotional expressions are strongly affected by cultural
ideas. The unwritten codes or display rules are internalized as a function of an
individual’s culture, gender, and family background. Nevertheless, the questions of how
far emotions are universal, how far they are socially constructed by cultures are still
very difficult to answer.
28
1. 1. 7. The Neuropsychology of Emotion
Doubtlessly, physiological dimension of emotion is very critical, although there
has not been generally accepted theory to date about emotional processing and
associated neural systems (Herba & Phillips, 2004). On the other hand, neuroscience
studies have demonstrated that emotion like cognition is distributed throughout the
nervous system and not located in any particular region. Also, selective impairments in
recognizing facial emotions without a deficit in facial identity, and conversely have
been reported indicating that different aspects of faces are processed in separate neural
subsystems. Three areas of the brain in forebrain however, are particularly important:
the hypothalamus, limbic system, and the cortex (Batty & Taylor, 2003; Kowalski &
Westen, 2005, p. 357; Frijda, 1986, p. 379; Candland et al., 1977, p. 152).
1. 1. 7. 1. The Hypothalamus
The hypothalamus that is situated in front of the midbrain and adjacent to the
pituitary gland helps regulate behaviors ranging from eating and sleeping to sexual
activity and emotional experience. In terms of emotion, this tiny structure becomes a
central link in a central circuit that converts emotional signals generated at higher levels
of the brain into autonomic and endocrine responses. Especially in anger or rage attacks,
hypothalamus is stimulated particularly in nonhumans (Kowalski & Westen, 2005, p.
79). Furthermore, because of its characteristics of producing hormones that affect other
endocrine glands, the hypothalamus is often thought as a part of the endocrine system.
As it is known that, the hormonal state of the organism contributes to the determination
of the individual’s reactivity to emotional stimuli or to the intensity of the response
(Candland et al., 1977, p.106). Even though hormones may not induce emotions, they
certainly seem to affect them.
1. 1. 7. 2. The Limbic System
It is a set of interrelated structures with diverse functions involving emotion,
motivation, learning, and memory. The limbic system includes the septal area, the
amygdala, and the hippocampus that is important especially for storing new
29
information. The role of septal area is newly understood and it appears to be involved in
some forms of emotionally significant learning such as avoiding aversive experiences
(Kowalski & Westen, 2005, p. 81). Stimulation of the septal area elicits pleasure
(Candland et al., 1977, p. 156). The amygdala, which is a complex of nuclei, resides in
the anterior temporal lobe involved in many emotional processes, especially learning
and remembering emotionally significant events. One of its primary roles is to attach
emotional significance to events (Kowalski & Westen, 2005, p. 81; Frijda, 1986, p.
381).
1. 1. 7. 3. The Cortex (Neocortex)
The cortex that reaches its largest development in human beings plays several
roles with respect to emotion. It allows people to consider whether a stimulus is safe or
harmful. People with damage to the regions of the frontal cortex that receive input from
the amygdala have difficulty making choices guided by their emotions. One of its roles
is interpreting the meaning of peripheral responses, for instance, a person’s shaky knees
and dry throat while speaking in front of a group gives a clue that she is anxious
(Kowalski & Westen, 2005, p. 81; Oatley & Jenkins, 1996, p. 144). Most of the
researches have shown that the right and the left hemispheres of the cortex appear to be
specialized, with the right hemisphere is dominant in processing emotional cues from
others and producing facial displays of emotion (Oatley & Jenkins, 1996, p. 144). In
other words, the right side of the cortex has been found to be more closely associated
with the processing of emotional events.
Furthermore, in terms of emotional facial expression, recent neuroscience
studies have demonstrated that particular brain regions are responsible in processing of
faces such as fusiform gyrus and superior temporal sulcus. Especially cortical
(prefrontal, frontal, and orbito-frontal cortices, occipito-temporal junction, cingulate
cortex, and secondary somatosensory cortex) and subcortical structures such as
amygdala, basal ganglia, and insula are important structures (Damasio et al., 2000).
Among these structures, the amygdala has often been linked with the mediation of
emotional behavior (Batty & Taylor, 2003; Amaral, 2002). Particularly processing of
30
fearful faces and sad faces are associated with amygdala, happy faces are linked with
cingulate sulcus, and orbital frontal regions are activated by angry faces. Disgust seems
to activate basal ganglia and insula (Batty & Taylor, 2003). Kowalski and Westen
mentioned that amygdala is associated with the expression of rage, fear and calculation
of the emotional significance of a stimulus (2005, p. 81). In other words, it is involved
in detecting others’ emotions from their facial expressions and vocal tone (Kowalski &
Westen, 2005, p. 359). It was found that impairment in the recognition of facial
expressions of fear is commonly found in patients with damage to amygdala (Adolphs
et al., 1994).
To sum up, emotional processes are distributed throughout the nervous system.
The emotional reaction to a stimulus appears to occur through two distinct neural
pathways: a quick response based on circuit from the thalamus to the amygdala, and a
slower response based on a more through cognitive appraisal, based on thalamus-to-
cortex-to-amygdala circuit. In both cases, the amygdala passes information to the
hypothalamus that is involved in regulating autonomic responses. The cortex plays
multiple roles such as interpreting the meaning of events and translating emotional
reactions into socially desirable behaviors (Kowalski & Westen, 2005, p. 360; Oatley &
Jenkins, 1996, p. 158).
1. 1. 8. The Development of Emotions
Facial expressions are very important for children to regulate their social
behaviors as well as for the quality of parent-child relationships. The abilities to
accurately interpret and express emotions through facial expressions develop during
infancy and childhood. As children mature, they learn to modify their emotional
expression in socially appropriate ways (Erickson & Schulkin, 2003; Dunn & Hughes,
1998). Around the age of 10 years, the ability to categorize facial expressions of basic
emotions reaches an almost adult level (Gosselin & Larocque, 2000).
Emotions are assumed as the first language that parents and infants
communicate with before the infant acquires speech. In terms of communication, faces
are not only interesting stimuli to view; they are also sources of social information.
31
Infants react to their parents’ facial expressions and tones of voice. In addition, this
communicative and social role of facial expression is the result of extended use of basic
survival responses (Erickson & Schulkin, 2003).
The sensitivity of babies to emotional expressions in faces grows slowly over the
first two years of life. Even three month-old babies may look longer at faces as the
intensity of the smile increases (Vasta et al., 2000, p.215; Santrock, 1997, p. 199).
Infants use eye gaze direction, along with facial expression, to gather information about
the environment by the end of the first year of life (Erickson & Schulkin, 2003).
By far the most important form of communication for the newborn is “crying”.
Crying is a part of the infant’s larger affective communication system. Darwin believed
that crying in newborns evolved as a means of providing the mother with information
about the baby’s state or condition (1934, p. 118). Caregivers should understand
whether baby is saying for example “I am hungry”, “I am wet” or “I am frightened” on
the basis of crying style that can be interpreted based in part on experience.
Newborns do not only use crying as a communication tool but also can
communicate “likes” using behaviors such as smiling, vocalizing, and gazing at an
object that they find interesting (Vasta et al., 2000, p.448; Oatley & Jenkins, 1996,
p.163). Many theorists believe that initially a close correspondence exists between what
babies feel and what they express (Vasta et al., 2000, p.449). Researchers have found
that even newborn babies possess all the facial muscle movements necessary to produce
virtually any adult emotional expression (Vasta et al., 2000, p.449; Oatley & Jenkins,
1996, p.163). For instance, facial responses to sweet that elicit positive facial responses
and bitter tastes that elicit aversive responses are expressed by infants and adults of
primate species (Erickson & Schulkin, 2003).
1. 1. 8. 1. The Development of the Expression of Emotions
Infants express some emotions earlier than other emotions. At birth, babies can
display “distress” by crying and “interest” by staring attentively. The facial expression
of “disgust” has been observed in newborns in response to sour tastes or odors
(Santrock, 1997, p. 200; Oatley & Jenkins, 1996, p.163). By 10 to 12 weeks of age,
32
smiling (reflecting pleasure) appears in response to the human voice or moving face.
Sadness and anger are first evidences in facial expressions at 3 or 4 months. Fearful
expressions do not appear until about 7 months. Guilt, shame, and embarrassment,
which are some of the complex affective responses, are not apparent until near the end
of the baby’s first year (Santrock, 1997, p. 200; Vatsa et al., 2000, p. 449; Oatley &
Jenkins, 1996, p.164). By four years of age, children can infer desires of others through
direction of eye gaze (Erickson & Schulkin, 2003).
In terms of the recognition of facial expressions, previous studies have
consistently shown that expression of happiness and sadness are more recognizable than
fear and disgust (Gosselin & Larocque, 2000). Gosselin & Larocque (2000) suggested
that expressions of anger and surprise were easier to identify than disgust but harder
than happiness and sadness. Nelson and Dolgin (1985) found that even 7 months old
infants were able to categorize between happiness-fear and happiness-surprise by
looking at the faces of different people.
In sum, even though infants can able to display expression of emotions, their
accurate recognition of expressions improves sooner. As they mature they able to
discriminate better. Thus, gradually they learn to express their emotions in a socially
appropriate way and identify facial expressions, which contribute to the appraisal of
other people’s emotions in order to organize social interactions.
1. 1. 9. Emotional Facial Expressions (EFE) and Cognition
1. 1. 9. 1. Affective/Mood Disorders, Anxiety Disorders and Recognition of
Emotional Facial Expressions (EFE): The Literature Review
It is apparent that emotional or affective states can influence cognitive processes
such as memory, learning, and judgments. Most of the studies have demonstrated that
mood or emotional states influence the way people make judgments, inferences, and
predictions.
Early theories such as Beck’s (1976) schemata theory and Bower’s (1981)
network theory proposed that in both anxiety and depression, cognitive biases operate
through information processing. The main difference between these two is about the
33
content of bias. (cited in Persad & Polivy, 1993). Specifically, anxious individuals
selectively perceive threatening information, whereas depressed individuals have a bias
for information related to sadness, loss and failure (Mogg, Millar, & Bradley, 2000;
Mogg & Bradley, 2006; Rohner, 2002). Several authors suggested that biases in
selective attention play a causal role in the onset and maintenance of anxiety and mood
disorders. In addition, during social interactions, misinterpreting emotional expressions
may interrupt the flow of conversation, may cause discomfort, and confusion both in the
speaker and the listener. Hence, these biases of facial expressions constitute one of our
purposes in this study.
From the research carried out so far, there appears to be substantial support that
individuals with affective disorders show some mild impairment, because it is accepted
that cognitive processes in depression is characterized by the negative schemata that
distort one’s world, the self and the future (Cavanagh et al., 2005). The negative
perceptual bias may be consistent with this negative cognitive triad. In other words,
depressed individuals tend to underestimate the probability of their own success and
overestimate the probability of bad events occurring in the future. Their negative
perceptions toward the world, self and future also affect their social interactions. They
are more likely to infer negative conclusions or appraisals from their spouses or friends’
behaviors (Persad & Polivy, 1993). Hence, these patients are usually expected to judge
facial stimuli more negative than do non-depressed individuals.
In order to examine the attributional style of depressed patients, Leppanen et al.
(2004) conducted a study in which recognition of different facial expressions were
compared in patients with moderate to severe depression. In this study, also reaction
times were measured. Totally, 18 depressed and 18 matched healthy controls were
presented neutral, happy, and sad expressions. As a result of this study, it was found that
depressed individuals and controls were equally accurate at recognizing happy and sad
faces. However, depressed individuals attributed neutral faces to sad faces and they
recognized neutral expressions both more slowly and less accurately than healthy
participants did. This result confirms that depressed individuals have some impairment
on recognition of neutral expressions due to their attentional bias towards negativeness.
34
The findings of reaction times will be mentioned in the next part in this study.
Similarly to the findings above, according to Hale (1998) depressed individuals
tended to perceive negative emotional states in others improperly. Specifically, these
individuals were more likely to attribute sadness to neutral faces, and neutral faces to
happy faces.
On the other hand, Mendlewicz and her colleagues (2005) designed a study in
which they aimed to investigate the recognition of facial expressions among female
adolescent inpatients with major depression and female adolescents with eating
disorders. They also compared these two inpatients groups with the healthy control
group. As a result of this design, they did not find any significant differences between
eating disorder group and controls in their facial expression recognition. As expected,
depressed patients demonstrated less accuracy rates in decoding angry expression than
inpatients with eating disorders and control group. This study also supports the
existence of decoding impairment in depression.
Furthermore, Surguladze et al. (2005) examined the neural basis of attentional
biases toward happy and sad facial expressions in major depressed and healthy
individuals. They found that preferential increases in neural response to sad but not
happy facial expressions were observed in depressed individuals. The results indicated
the existence of association of attentional biases and neural basis for the negative
cognitions and social dysfunction in depressed individuals.
There are also other studies, which are designed to compare major depression
with other disorders in terms of facial expression impairments. For instance, Weniger et
al. (2004) examined facial expression recognition abilities in subjects with various
schizophrenia subtypes and subjects with major depression. As predicted, disorganized
and paranoid schizophrenic subjects showed strong impairments, whereas depressive
subjects demonstared only minor impairments. Surely, schizophrenia is one of the
disorders, which has deleterious effect on the mind. The authors found that both
schizophrenia groups and depressed individuals identified happy expressions at higher
rates than negative facial expressions, interestingly depressed individuals rated
expressions less aroused than other groups.
35
In sum, because of the exhibition of poor social communication skills of
depressed individuals, our one of the hypotheses was that these interaction problems
might be associated with deficits to recognize facial expressions.
1. 1. 9. 2. Anxiety Disorders, Affective/Mood Disorders and Reaction Times
towards Emotional Facial Expressions (EFE): The Literature Review
There has been extensive research about anxiety, which is supposed to interfere
with cognitive and emotional processing. It is observed that anxious individuals are
more sensitive to threatening information and they are more likely to exhibit attentional
bias or hypervigilance and evaluative bias to these threatening-content stimuli. It is
assumed that attentional vigilance for threat may be an important figure in both causing
and maintaining anxiety (Bradley et al., 2000; Mogg et al., 2000; Mogg & Bradley,
2006). In each anxiety disorders, vigilance appears according to the domain concern of
the individuals. Specifically, in panic disorders physical threats, in social anxiety
socially threatening situations, in generalized anxiety disorders idiosyncratic worries
constitute the subjects of biases (Rossignol et al., 2005; Mansell et al., 2002).
Several studies about the existence of attentional biases, generally used Stroop
task in which participants are asked to name the colors of the words as faster as possible
without ignoring the content. The findings of these studies usually manifested that
participants who had anxiety, expressed greater interference in color naming tasks,
which were associated with their fears. Nevertheless, when Stroop task method was
found as questionable, recently probe detection task has been developed. Moreover,
nowadays in order to obtain ecological validity, facial expressions have begun to use.
(Mogg & Bradley, 2006; Bar-Haim et al., 2005; D’Argembeau et al., 2003).
With respect to facial expressions, there have been discrepant findings of the
studies so far. For instance, Bradley et al. (2000) proposed that anxious individuals were
faster in responding to probes that replace threat rather than neutral stimuli. Accordant
with the study of Bradley et al. (2000), Mogg and Bradley (2006) found consistent
findings with their primary hypothesis, which was initial and rapid attentional bias for
fear-related stimuli in spider-fearful individuals. In other words, high fear is associated
36
with an enhanced initial attentional bias for fear-relevant stimuli. However, in a study of
Mogg et al. (2000), findings revealed that there were no significant differences between
patients with generalized anxiety disorders and normal control individuals in terms of
reaction times toward threat, sad and happy faces. Also, they did not find any significant
results in individuals with depressive disorder in terms of showing an attentional bias or
processing bias for sad faces. However, Leppanen et al. (2004) found that depressed
individuals were slower to react toward neutral faces than sad faces, whereas control
individuals recognized neutral faces faster than sad ones. They found that healthy
individuals recognized happy expressions faster and more accurately than sad
expressions.
Furthermore, Surcinelli et al. (2006) investigated the relationship between trait
anxiety and recognition of emotional facial expressions. They found that individuals
with high-trait anxiety recognized only fear faces significantly better than individuals
with low-trait anxiety. And they were more likely to classify ambiguous faces as
expressing fear. The two groups did not differ in terms of the recognition of anger,
sadness, happiness, surprise, disgust, and neutral faces. As it is known, a primary
function of fear is considered a facilitation of the detection of danger in the
environment. Participants with high anxiety may perceive many daily situations as
threatening and they organize their lives based this fear expectation.
On the other hand, Philippot and Douilliez (2005) found that a group of anxiety
disorders such as generalized anxiety disorder, social phobia, panic disorder with
agoraphobia, obsessive-compulsive disorder did not cause any attentional or evaluative
biases in the process of threatening facial expressions. It was assumed that especially
socially anxious individuals would evaluate facial expressions more negatively.
However, in three studies, they presented a set of photographs of EFE to patients with
generalized anxiety disorder, patients with social phobia, patients suffer from panic
disorder with agoraphobia, obsessive-compulsive disorder and surely to a control group.
Their decoding accuracy was measured based on participants’ ability to infer the
emotion that was presented on computer screen. As a conclusion, no significant
differences could be found between anxiety disorders and control group in terms of EFE
37
decoding accuracy. Indeed, the authors believed that these unexpected results were due
to several methodological limitations.
In the study of D’Argembeau et al. (2003) which was designed to examine
identity and expression memory in social anxiety, results showed that individuals with
high and low socially anxiety did not differ on total correct responses and this
expression memory was better for happy than angry expressions in both groups.
However, they added that high anxious participants remembered happy faces less than
low anxious participants did. This decreased encoding of positive information in
memory may take a role in maintenance of social anxiety.
On the other hand, Cooper et al. (2006) who contribute new dimensions to the
issue of attentional bias in anxiety investigated the existence of an attentional bias to
angry faces in non-anxious populations by using the dot-probe task in 100 ms and 500
ms conditions. They expected the inability to find any evidence for attentional cues.
They used thirty pictures from Ekman and Friesen (1976) set of emotional expressions.
This set includes neutral, happy, and angry expressions. Participants were asked to press
the keyboard button when they saw a dot. There were eight conditions: two emotional
expressions (angry or happy), two probe locations, and two gaze directions. The
analysis was based on the reaction times for correct responses. Results revealed that at
100 ms there was an attentional bias towards the location of the relatively threatening
stimulus; the angry face in angry/neutral pairs, the neutral face in neutral face in
neutral/happy pairs. In sum, Cooper et al. (2006) examined whether previous attempts
to observe an attentional bias towards angry expressions in the general populations
using the dot-probe task would fail when they used 500 ms dot-probe task. However, in
100 ms condition, the findings were interpreted as vigilance to the angry faces for
angry/neutral pair, as avoidance of the happy faces for neutral/happy pair. The authors
elucidated these results as an attentional bias towards threat, which is a universal feature
of human cognitive processing, and this feature is not only specific to anxiety. Instead,
evolutionarily, humans detect threat from their environment in order to fight or flight.
Angry facial expression is one of the threat signals for survival.
38
Furthermore, recent studies have focused on the differing brain regions for
different emotions, however little attention has been paid to the timing of this emotional
processing. For this aim, Batty and Taylor (2003) used event-related potentials (ERPs)
in their study in order to find out latency and amplitude differences in timing of
processes between fearful, disgusted, sad, surprised, happy, and neutral faces.
According to them, six basic facial emotional expressions are processed very quickly in
normal individuals suggesting that facial details, reflecting emotional content, are
included in rapid processing. Their study concluded that positive emotions (happy and
good surprise) evoked the measure component-N170 significantly earlier than negative
emotions (fear, disgust, and sadness) and the amplitude of N170 evoked by fearful faces
was larger than neutral or surprised faces. In other words, negative emotions were
processed later than positive emotions according to the localization in the brain.
Similar to the study of Batty and Taylor, Rossignol (2005) examined whether
there was a non-clinical anxiety bias toward facial expressions, based on STAI scores.
For this aim, twenty students were distinguished as high or low anxious group. By using
event-related potentials, they investigated neurophysiological dimension of non-clinical
anxiety toward fearful and happy expressions. Consequently, the amplitude of N170
evoked by fearful faces was larger than happy expressions. Even though there was no
significant difference between anxiety groups, fearful expression was processed earlier
than happy expression. This increase was found only for the expression of fear. This
outcome was interpreted, as it might be the result of unconscious attention.
To conclude, even though still no firm conclusion can be drawn from the
existing studies, it is obvious that anxiety and depression affect the processing of facial
expressions in terms of reaction times or accurate decoding. However, there are still
debates in the determination of the most affected expression and it is still difficult to
find the clear-cut results of information processing systems in depression and anxiety.
39
1. 1. 9. 3. Other Psychopathological Disorders, Recogntion of Emotional Facial
Expressions (EFE) and Reaction Times towards EFE: The Literature Review
The deficits in social interactions are shown in some psychopathological
disorders may be partly related to difficulties in the recognition of facial expressions.
Such deficits have been demonstrated in various clinical populations such as
schizophrenia, personality disorders especially psychopathic and borderline personality
characteristics, Alzheimer’s disease, Parkinson’s disease, autism and attention-deficit
hyperactivity disorder (Shayegan and Stahl, 2005; Dujardin et al., 2004; Mendlewicz et
al., 2005; Roudier et al., 1998; Blair et al., 2004).
The empirical evidences so far have displayed that individuals with
schizophrenia have stronger deficits in the recognition of facial expressions. These
deficits may prevent them to interpret others’ intentions, goals, and desires. In one of
the most prominent studies, Weniger et al. (2004) compared different subtypes of
schizophrenia (disorganized, paranoid, and residual types). The results indicated that
particularly individuals with disorganized schizophrenia were the most impaired
subtypes in all schizophrenia spectrums. Whereas individuals with paranoid
schizophrenia were significantly impaired in identifying sadness and fear, disorganized
individuals had impairment in all emotions. All subtypes were better on happy than
disgusted, angry and sad faces. The expressions of surprise and fear were found as the
most difficult expressions to identify than other expressions for all groups. This study
has confirmed that one of the markers in schizophrenia can be a deficit in reading facial
expressions.
Similar to Weniger et al., Martin et al. (2005) examined the abilities of patients
with schizophrenia in recognition of facial expressions and identity matching. Totally
20 patients and a control group that was composed of 20 healthy individuals
participated in the study. They were asked to choose the correct emotion or correct
person of the photos of five persons expressing five different emotions (happiness,
sadness, fear, anger, and disgust). Consequently, performance in patients with
40
schizophrenia was more impaired than controls. As predicted, they were found as less
successful on both identity-matching and reading facial expressions.
Exner et al. (2004) investigated the volume of amygdala in patients with
schizophrenia in their recognition of emotional expressions. 9 patients with paranoid
schizophrenia, 6 undifferentiated subtypes, 1 disorganized subtype and 16 matched
control individuals were asked to match the corresponding emotion on a probe stimulus
of a face exhibiting one of the six expressions. As expected, individuals with paranoid
schizophrenia showed a deficit in recognizing all emotional expressions. Also, this
study has confirmed that cognitive deficits are more likely to appear in disorganized
symptoms. As hypothesized, the findings have proved that there was a reduced volume
in right amygdala in schizophrenic individuals. That decrease can be associated with the
impairment in the recognition of facial expressions.
From the research carried out so far, there appears to be a substantial support
that individuals with schizophrenia have cognitive impairments in terms of recognition
facial expressions. That impairment has been linked to the serious interruption in their
social relationships.
Besides schizophrenia, recently, most studies have demonstrated that in
Parkinson’s disease (PD) because of the enormous loss of dopaminergic neurons,
cognitive deficits arise. Mainly, these deficits concern tasks including planning or
organizing the sequential actions. (Dujardin et al., 2004). Dujardin et al. (2004)
examined whether PD has an effect on any impairment in reading facial expressions. 18
unmedicated PD patients and healthy individuals participated in this study, as a
conclusion, they found that untreated PD patients were significantly impaired in the
recognition of all facial expressions.
Likewise, Roudier et al. (1998) investigated the recognition of facial expressions
and processing faces identity in patients with Alzheimer’s disease (AD). Based on
assumption, which is that specific brain lesions affect the ability to discriminate
unfamiliar faces, they compared 31 AD patients with 14 control group. These
participants were administered to tasks of discrimination of faces and emotions by
presenting emotional faces test of Ekman and Friesen (1975). The findings
41
demonstrated that AD patients were significantly impaired in discrimination of facial
identities, and in naming and pointing emotions. However, unexpectedly, discrimination
of facial expression was preserved in AD patients, only verbal identification of
emotions significantly impaired. These results suggested that the operations of facial
discrimination and facial discrimination are separate issues. Surely, these findings bring
new debates on brain structures and damages of Alzheimer’s disease especially on
linguistic area. Parkinson’s and Alzheimer’s Diseases are relatively recent studies that
still have no firm conclusions.
Nowadays, there have been studies with the individuals of personality disorders.
It is accepted that one of the symptoms of borderline personality disorder is their
significant problems in interpersonal relationships that may be associated with facial
expression decoding. Based on this assumption, Renneberg et al. (2005) investigated the
expressiveness of facial reactions to emotion-eliciting film material among 30 female
Borderline Personality Disorder (BPD) inpatients, depressed inpatients, and non-clinical
control group. They expected depressed patients to display less facial expression of
emotions than normal control group, and BDP patients to show more facial reactions
than non-clinical group. As expected, the results indicated that depressed individuals
showed less happy expressions when compared to control group, whereas clinical
groups were not found as different from each other in the reading of facial expressions
of happiness. There was almost no difference between BDP patients and control group.
Interestingly, regarding surprise expression, BDP patients displayed no surprise
expressions while watching the film.
Similarly, psychopathic individuals are accepted as having low level of fear
emotion and empathy dysfunction (Patrick, 1994). Because of these features, they
display emotional dysfunctions and relationship problems. In order to clarify this
assumption, Blair et al. (2004) investigated the ability of psychopathic individuals to
process emotional expressions. They expected a recognition deficit particularly on
negative expressions. As predicted, the results displayed that psychopathic individuals
showed selective impairment for the recognition of fearful expressions than control
individuals. In other words, they did more errors for fearful expressions than other
42
expressions. In addition, these individuals considered that fearful faces were the most
difficult expression to recognize. Researchers proposed that this impairment could be
associated with the amygdala dysfunction.
In support of Blair et al., Montagne et al. (2005) studied on the accuracy of
perception of emotional faces in normal individuals with scoring high or low on
psychopathic personality characteristics that are characterized by lack of fear. As
expected, the results showed that participants with high scores on psychopathic
personality characteristics were significantly less accurate in recognizing the expression
of fear when compared to participants with low scores on psychopathic personality
characteristics. These two studies have suggested that individuals with psychopathic
tendencies have difficulty to distinguish fearful expression. This inability may be related
with amygdala dysfunction that can be responsible from their antisocial behavior and
their inability to perceive of victim’s distress.
To sum up, it is proved that identification difficulty of emotional facial
expressions is not only specific to alcohol dependence. There are many disorders, which
have proved serious impairments in their decoding of expressions.
1. 2. ALCOHOL DEPENDENCE or ALCOHOLISM
1. 2. 1. Ethyl Alcohol
Literally, alcohol has been derived from an Arabic word al kihl that refers to the
essence of something and it is accepted as the first psychopharmacological agent
(Ceylan & Türkcan, 2003. p.1). Anthropological evidences have suggested that use of
alcohol has been widespread throughout history. The origins of alcohol use pre-date
recorded history and it is believed that ethanol was known even by Neolithic man. For
instance, in China archaeological evidence dates the origin of alcohol from fermented
grain to some 6000-7000 years ago (Heather, Peters & Stockwell, 2001, p. 16). Alcohol
can be described as the world’s favorite substance. While the pains of alcohol are the
numerous and diverse, its popularity continues.
43
1. 2. 2. Alcohol and Harm
In fact, use of alcohol and related problems were encountered even in ancient
ages such as Ancient Greek, Roman, or Egypt. Hippocrates, the Greek physician
described symptoms such as nausea, insomnia, palpitations and delirium which,
centuries later, became a familiar part of the clinical picture of “alcoholism”. However,
scientific attention to alcohol problems has accelerated during the past 30 years, when
substantial advances have occurred in understanding of drinking problems as well as
their prevention and treatment. It has been known that alcohol consumption is
responsible for increased illness and death (Room, Babor & Rehm, 2005). However,
alcohol and health outcomes are complex and multidimensional. Alcohol has been
shown to be causally related to more than 60 different medical –physical and mental-
conditions. It causes many disruptions in social, occupational, and family life (Miller,
1990; Hodgson et al.).
Furthermore, gender differences in the consequences of drinking alcohol are
large and consistent. Generally, these studies suggest that women appear to suffer
serious negative consequences of alcohol consumption earlier and to a greater degree
than men do. Specifically, they suffer more cognitive and motor impairment due to
heavy alcohol than men (Nolen-Hoeksema, 2004). These negative effects on cognitive,
motor, and reproductive health as well as social norms pressures on women mostly
discourage women from excessive alcohol intake when compared to men. Therefore, in
our study merely males were used.
1. 2. 3. Alcohol Dependence or Alcoholism
Specifically, alcohol can be a problem, but identifying who is an alcoholic, who
is a problem drinker, and who is a responsible drinker can be difficult at times. A person
is identified as having alcoholism when s/he is physiologically dependent on alcohol,
and therefore shows withdrawal symptoms when no alcohol has been consumed.
Problem drinkers are not physiologically addicted to alcohol, but still have a number of
problems stemming from alcohol consumption, including problems with work and
family, and health-related complications (Kowalski & Westen, 2005, p. 391).
44
Alcoholism or alcohol dependence is a deeply pervasive, malignant, long-term,
and multifaceted problem (Hoes, 1997). It can be defined as a condition in which
individuals drink alcohol habitually and excessively and individuals continue to drink
even though this results in serious harm to their physical, mental health and family and
school or occupation (Berger, 1993, p.11). In other words, alcoholics have problems to
keep their drinking habit under control. On the other hand, some theorists suggest that
alcoholism is a family disease because the entire family hurts when one or more
members are alcohol dependent. A serious drinking problem mostly lead to economic
problems, a loss of self-respect, psychological and emotional difficulties such as
divorce, suicide, delinquency (Berger, 1993, p.11).
1. 2. 4. History of Classification
Various classification systems were published by medical writers in US and
Europe. Bruhl-Cramer introduced the concept of dipsomania or drink seeking. In 1849,
the term alcoholic was coined by Magnus Huss in Sweden to describe people who
suffered negative consequences of alcohol use. Between 1850 and 1941, totally 39
classifications of alcoholism were developed around the world. Generally, these
classification systems were rooted on excessive drinking (Ceylan & Turkcan, 2003, p.
2; Heather, Peters & Stockwell, 2001, p. 49).
In US from the 19th century to 1933 alcohol was seen as a dangerous substance
that should be avoided. When alcohol was legalized in 1933, American disease model
of alcoholism has started. In 1941, Bowman and Jellinek published an elaborate
classification scheme for the disease, based on the pattern of drinking frequency,
etiology, co-morbid disorders, and ability to abstain (Heather, Peters & Stockwell, 2001,
p. 49). For instance, Jellinek postulated five species of alcoholism: alpha, beta, gamma,
delta, and epsilon. His classification became the most popular alcohol typology for the
next 20 years. However, these classification systems were not found as sufficient to be
used currently.
45
1. 2. 5. Current Diagnostic Classification
Current nosology for alcohol use disorders and dependence relies on the
Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric
Association, 1952, 1968, 1980, 1987, 1994) and the International Statistical
Classification of Diseases, Injuries, and Cause of Death (ICD; World Health
Organization, 1967, 1978, 1989, 1992). Current Diagnostic criteria for both the DSM
and ICD are based on years of evolution of the concept of excessive use, associated
negative consequences, and physical dependence. However, as illustrated below using
DSM-IV one can be diagnosed as Alcohol Dependent without having physiological
dependence. The Alcohol Abuse diagnosis is more detailed and better operationalized,
and the threshold is lower, that is, only one of the four symptoms must be positive in
order to get a diagnosis. Diagnosis of Alcohol Dependence and Alcohol Abuse are
mutually exclusive. A patient who has ever been diagnosed with Alcohol Dependence
cannot be diagnosed with Alcohol Abuse (Heather, Peters & Stockwell, 2001, p. 57).
Based on DSM-IV-TR (APA, 2000) Alcohol use disorders are the alcohol-
related psychiatric disorders. These include alcohol abuse, which involves persistent
drinking behavior in the face of repeated social, interpersonal, and occupational
problems that are due to excessive alcohol consumption. Alcohol dependence includes
these psychosocial problems, but can also involve physiological dependence on alcohol,
such as tolerance and withdrawal symptoms. This syndrome is often referred to as
alcoholism. Heavy drinking and binge drinking are operationalized in different ways
across different studies. Alcohol-related problems will be used to refer scores on
measures of negative psychosocial consequences of excessive alcohol consumption
such as arrest for drunken driving. Finally, social drinkers is the label for people who
drink alcohol at least occasionally, but do not meet the criteria for alcohol abuse or
dependence (Nolen-Hoeksema, 2004).
46
DSM-IV Criteria for Alcohol Dependence (APA, 1994)
A. A maladaptive pattern of substance use, leading to clinically significant impairment
or distress as manifested by three or more of the following occurring at any time in the
same 12-month period.
(1) Tolerance, as defined by either of the following:
a. Need for markedly increased amounts of a substance to achieve intoxication
or desired effect.
b. Markedly diminished effect with continued use of the same amount of the
substance.
(2) Withdrawal, as manifested by either of the following: (a) characteristic withdrawal
syndrome for the substance, or (b) the same (or a closely substance is taken to relieve or
avoid related) withdrawal symptoms.
(3) The substance is often taken in larger amounts or over a longer period than was
intended.
(4) There is a persistent desire or unsuccessful efforts to cut down or control substance
use.
(5) A great deal of time is spent in activities necessary to obtain the substance, use the
substance, or recover its effects.
(6) Important social, occupational, or recreational activities are given up or reduced
because of substance use.
(7) The substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
the substance.
Specifiers;
*With a physiological dependence
*Without a physiological dependence
47
1. 2. 6. Epidemiology
Nowadays the most common substance-related disorder has been alcoholism
around the world. Surely, a number of genetic and environmental variables contribute to
the development of alcohol abuse.
• As in other Western countries, alcoholism is the third largest health problem in
the US, following heart disease and cancer.
• There is a sex difference (male/female) of 17.7 % vs. 6.3 %.
• In the US, an estimated 13 million or 7.4 percent of the population meet the
diagnostic criteria for alcohol abuse or alcoholism. When alcoholism is an index
disorder, its lifetime prevalence in males under the age of 60 years varies
between 9.8% (USA) to 43.8% (Canada).
• The highest prevalence is in 14-19 to 40-59 year-old.
• More than one half of American adults have a close family member who has or
has had alcoholism (Hoes, 1997; Health Risk, 2000, cited in Kowalski &
Westen, 2005, p. 391).
A research indicating that alcohol use in Turkey is increasing, particularly in the
last twenty years, has been recently carried out by Ministry of Health. The alcohol use
prevalence was found to be 42.6% and the rate of regular alcohol use was 20.5% in
young population. Additionally, Ceylan and Türkcan (2003) reported that in a sample of
1550 individuals, aged between 12 and 65, representing İstanbul population in terms of
age, gender and districts, prevalence of alcohol use was 33.5%. Furthermore, 25.6% of
the sample stated that they currently use alcohol, 7.9% stated they cut down alcohol use
and those who use alcohol, 12.6% stated that they use alcohol more than once during a
day.
To sum up, accordant with research carried out in abroad, studies on alcohol
prevalence in Turkey displayed that alcohol use has been increasing among population,
particularly in young adults. Moreover, they demonstrated that prevalence of alcohol
dependence disorders have been also increasing.
48
1. 2. 7. Alcohol Dependence and Co-morbid Disorders
Alcohol dependence is usually exhibited other forms of mental disorder
particularly mood disorders, anxiety disorders and occasionally antisocial personality
disorders (Oltmanns & Emery, 2001, p.382; Preisig et al., 2001).
The relationships between alcohol dependence and mood or anxiety disorders
have been well documented in many studies. The associations between alcoholism,
mood, and anxiety disorders have not only been found in clinical settings, but also in
community samples. It has been suggested that individuals with alcohol dependence
show moderate to severe depressive symptomatology and they are more prone to
anxiety symptoms than non-dependent individuals do (Tedstone et al., 2004; Gratzer et
al., 2004, Terra et al. 2006). Grant and Harford (1995) have suggested that dependent
individuals up to 70% meet criteria for a lifetime diagnosis of depression. Preisig et al.
(2001) postulated that in alcohol dependent individuals the frequency of depressive
symptomatology ranged from 16% to 59%.
Some researchers believe that alcohol misuse especially in men is a mask for
depression (Nolen-Hoeksema, 2004). Similarly, regarding the anxiety disorders, Gratzer
et al. (2004) found that 35-54% of individuals with an anxiety disorder had a lifetime
diagnosis of an alcohol use disorder. Additionally, their findings revealed that
depression had a stronger relationship with alcohol dependence than anxiety. In another
study, again it was found that there was a stronger association between alcohol misuse
and negative affect such as anxiety and depression (Berger and Adesso, 1991).
Ceylan and Türkcan (2003) pointed out on gender differences about the
relationship between alcohol use and some mental disorders. They proposed that in men
mostly antisocial personality disorder and anxiety disorders-phobia and panic disorder
(15%), depression (5%) however in women mostly anxiety disorders-phobia and panic
disorder (38%), depression (19%), antisocial personality disorder (10%) displayed co-
morbidity with alcoholism.
Possible sources of the associations between depression, anxiety disorders, and
alcoholism have been studied extensively. Generally, it is assumed that alcohol is used
in order to manage or regulate the affects of drinkers, to increase positive affect when
49
people are fatigue, decrease when they are anxious, or over aroused. However, the
evidence regarding the nature of these associations remains vague.
In sum, the above studies provide strong evidences that both anxiety disorders
and depression are associated with high rates of alcohol dependence or alcohol abuse.
Hence, in this study one of the aims is to find the accordant findings with previous
studies.
1. 2. 8. Alcohol Dependence and Cognition
In recent years, substantial evidences have shown that alcohol dependent
individuals suffer some degree of brain dysfunction. It has been proved that chronic
alcohol dependence has deleterious effects on central nervous system functioning
(Chelune and Parker, 1981). Long-term chronic alcohol misuse causes disturbances just
like brain aging.
Neuropsychological studies have revealed that dependence causes essential
cognitive impairments such as on neocortex or on hippocampus that decrease in abstract
concept-formation or abstract reasoning ability, cognitive flexibility, problem-solving
ability, new learning, perceptuomotor speed, accuracy processes and lastly
visuoperceptual area and surely memory processes (Miller, 1990; Brandt & Provost,
1985; Garcia-Moreno et al., 2002; Chelune and Parker, 1981; Loas et al., 2000).
Chelune and Parker (1981) proposed that alcohol dependent individuals were
good at on familiar settings but they had troubles on complex or new settings. As a
result of their study, whereas the verbal skills remained same, performance and adaptive
abilities significantly disrupted when compared to non-dependent individuals.
Although Chelune and Parker (1981) did not find any significant results
regarding verbal skill impairment, Monnot et al. (2001) found that on affective prosody
functioning (nonlinguistic feature of language such as pitch, innotation patterns, stress,
timing, rhythm etc) which, is an essential element in social interaction localized to the
right hemisphere, detoxified alcoholics demonstrated significant deficits in their ability
to identify emotion in the voices of others.
50
Accordant with previous studies, Obernier et al. (2002) postulated that alcohol
dependent individuals displayed decreased neuropsychological performance on the tests
of learning, memory, abstract thinking, problem solving, visuospatial and perceptual
motor functioning, and information processing. In addition, they suffered damage to the
hippocampal formation, frontal cortex, and grey and white matter loss.
As conclusion, most of the literature up to now has focused on traditional
intellectual cognitive skills. However, other skills may be impaired in alcohol abusers or
in alcohol dependent individuals. For instance, emotional processing abilities in alcohol
dependent individuals have been studied less extensively with a few notable exceptions.
Thus, in this study the relationship between emotional facial expression and alcohol
dependence was focused.
1. 2. 9. Alcohol Dependence and Recognition of Emotional Facial Expressions
(EFE): The Literature Review
It is apparent that alcohol dependent individuals frequently have severe
interpersonal difficulties. It has been also proved that accurate recognition of facial
expressions enables healthy social relationships. Numerous studies have been designed
to examine the association of alcohol dependence with the recognition of facial
expressions especially towards negative emotions. Some studies have confirmed this
assumption and some have not.
In order to find out any deficit in the perception of alcohol dependent
individuals, Philippot et al. (1999) conducted a study. As a result of this study, they
found that recognition of facial expressions seemed to be severely impaired in
recovering alcoholics. They suggested that particularly alcoholic dependents had a bias
in the recognition of angry and contempt. Specifically, according to these authors,
alcoholic participants had a systematic bias in interpreting faces expressing disgust as
showing anger or contempt.
In accordance with the findings of Philippot et al., the findings of Frigerio et al.
(2002) study manifested that alcohol dependent individuals did more errors in the
recognition facial expressions. However, it was found that alcohol dependent
51
individuals had a specific deficit in recognizing sad faces. Based on the study of Frigero
et al. (2002), alcoholics had a tendency to interpret sad faces as anger or disgust. If so,
they may be more sensitive to feelings to threat from faces looking at them and they are
more likely to interpret facial expressions as hostile than as sadness.
Furthermore, according to the study of Philippot et al. (1999), alcohol dependent
individuals also showed overattribution of anger and contempt and they systematically
overestimated the intensity of all emotions. However, Kornreich et al. (2001) found that
recovering alcoholics tended to overestimate the intensity of the EFE for only happiness
and anger. Similarly Kornreich et al. (2001) found that recovering alcoholics displayed
accuracy deficits especially for happiness, anger, disgust, and sadness but not for fear.
Both studies did not find any gender differences in decoding EFE (Philippot et al.,1999;
Kornreich et al., 2001).
However, inconsistent with the findings of both Philippot et al. (1999) and
Kornreich et al. (2001), Townshend & Duka (2003) displayed that alcoholics showed
different patterns in responding on anger and disgust but they did not find any
differences between experimental and normal control groups in responding on happy,
sad and surprised expressions.
Kornreich et al. (2003) replicated their studies in order to explore that whether
impairment in EFE decoding is specific to alcoholism compared with opiate
dependence. They found that accuracy scores were significantly lower in alcoholics
rather than opiate dependents. Surprisingly, they noted that opiate dependence was also
associated with an impaired EFE decoding however less than alcoholism.
That is to say, substantial evidences have presented the deficiency in the
recognition of facial expressions in alcohol dependent individuals whereas still there
have been no stable conclusions yet.
To sum up, alcohol perhaps more than any other substances, touches the lives of
most people dramatically in the whole world as well as in Turkey. The long-term use of
alcohol has devastating impact on many areas of a person’s life. Besides the effect on
organ systems, especially the disruption of relationships with family and friends can be
very painful. On the other hand, one of the crucial sources in regulating interpersonal
52
relationships in daily life depends on the ability to perceive the emotional state of other
people. However, it seems obvious that alcoholic individuals frequently have severe
interpersonal difficulties that may be related to poor or inaccurate perception of
emotional facial expressions (EFE).
1. 3. Purposes of the Present Study
Emotional expressions are important sources in terms of social communication
in daily life. Therefore, any confusion or any impairment in understanding emotional
facial expression may interrupt daily relationships. A growing number of studies have
demonstrated that individuals with some disorders such as affective disorders, anxiety
disorders, personality disorders, psychotic disorders, and substance disorders have some
deficits in reading these expressions. Some may have attentional bias in reading or
reacting toward sad expressions, some in angry or fearful that they assume as
threatening (Mogg et al., 2000; Rohner, 2002; Blair et al., 2004).
Numerous studies have shown that long-term alcohol consumption can lead to
cognitive and neurological impairments. So far, little attention has been given to studies
that are related with the recognition deficits in alcohol dependent individuals. These
rarely studies consistently have proved that individuals with alcohol dependence have
some impairments in recognizing emotional expressions, which may be associated with
interpersonal conflicts (e.g. Garcia-Moreno et al., 2002; Frigerio et al., 2002; Kornreich
et al., 1998, 2001, 2002; Philippot, 1999).
Thereby, this study aimed to investigate the accuracy of recognition of
universally recognized Emotional Facial Expression (EFE) -happiness, sadness, anger,
disgust, fear, surprise, and neutral expressions- and to measure the manual reaction
times (RT) towards these expressions in alcohol dependent inpatients and in normal
control group. Depression and anxiety levels were measured that may influence the
results in terms of attentional or evaluative biases. Besides the differences of two
groups, some similarities would be predicted in terms of the tendency of expressions.
53
1. 4. Hypotheses of the Study
1. Alcohol dependent group would score higher than normal control group on the
CAGE inventory, Beck Depression Inventory, State-Trait Anxiety Inventory,
and Symptom Checklist (SCL-90-R) and its nine subscales as compared to
normal control group.
2. Alcohol dependent group would show more deficits in total emotional
recognition accuracy than normal control group.
3. Alcohol dependent group would show more deficits especially in the
recognition of negative emotional expressions, which are anger, fear, sad, and
disgust, than non-dependent individuals. In other words, it was predicted that
alcohol dependents would display less accurate scores than normal control
group.
4. Alcohol dependent group would react faster to the negative expressions as
compared to normal control group.
5. When Beck Depression Inventory, State-Trait Anxiety Inventory, and SCL-90
were accepted as covariates, alcohol dependent group would show more
evaluative bias (misinterpretation) especially toward negative expressions as
compared to normal control group.
6. When Beck Depression Inventory, State-Trait Anxiety Inventory, and SCL-90
were accepted as covariates, alcohol dependent group would show more
attentional bias/hypervigilance and thus they would react faster to the negative
expressions as compared to normal control group.
7. The most correct recognition would be for happy facial expression than other
expressions for both groups.
54
CHAPTER II
METHOD
2. 1. Participants
In order to test the proposed hypotheses, totally 101 volunteers participated in
the current study. From Alcohol and Substance Treatment Center (AMATEM) of
İstanbul Mazhar Osman Bakırköy Education and Research Hospital for Psychiatry and
Neurological Diseases, 51 (50%) detoxified alcohol dependent inpatients who were
treated with antidepressants or anxiolytics at the time of the study and 50 normal control
group (49%) that were match for age, sex and years of education participated. Inpatients
who were treated with antipsychotics were excluded from the study. At least 10 years of
dependence was the inclusion criterion for the inpatient participants. All the participants
were males because it was easier to access. The presence of a psychotic disorder,
antisocial personality disorder, or dementia led to exclusion from the study.
Approximately, inpatients with 15 days participated in the study.
As a control group, volunteer judges, prosecutors, clerks, and other employees in
İstanbul Beyoglu Courthouse; teachers and other personnels in a private education
centre; volunteers in ordinary cafés participated in the present study. While selecting the
participants for control group, first they were administered CAGE inventory to detect
possible alcohol dependence.
The mean age of all participants was 46.21 (SD = 7.19, range = 30-67). The
mean age of alcohol dependent group was 45.50 (SD = 7.56), control group’s mean age
was 46.94 (SD = 6.79).
2. 2. Materials
Both groups were administered a battery of self-report measures including
Demographic Information Form, CAGE Alcoholism Questionnaire, The Symptom
Checklist (SCL-90-R), Beck Depression Inventory (BDI), and State-Trait Anxiety
55
Inventory (STAI) and finally a Emotion Recognition Test that was constructed by using
a set of photographs from Ekman and Friesen’s (1976) “Pictures of Facial Affect”.
2. 2. 1. Demographic Information Form
It was developed by the authors in order to collect some information including
gender, age, educational level, marital status, occupational status, years of alcohol use,
hospitalization number, use in family, and reason of use. A copy of this form was
presented in Appendix A.
2. 2. 2. CAGE Alcoholism Inventory (1968)
The CAGE (Cut Down, Annoyed, Guilty, Eye Opener) inventory that is quite
simple and rapid was originally developed by Ewing and Rouse in 1968. It was
designed to detect current alcoholism. It consists of four items that are asked to with
respect to an occurrence during the previous one year. Each item can have either yes or
no response. Two or more positive answers are the common cut-off for detecting
alcoholism. The items are:
1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink in the morning? (eye opener)
It has proven to be a valid instrument (Bisson et al., 1999, Ewing, 1984, Bühler,
et al. 2004). It shows high internal consistency with a Cronbach alpha coefficient of
.85. Furthermore, it shows some similarities with DSM-IV dependence items such as
cut-down attempts in CAGE and quit/cut-down attempts in DSM-IV; annoyed in
CAGE, social problems in DSM-IV; eye-opener in CAGE, tolerance and withdrawal
in DSM-IV (Bühler et al., 2004). Although this simple questionnaire is used in
medical area, its reliability and validity coefficients could not have been found for
Turkey. A copy of the Turkish version of CAGE was presented in Appendix B.
56
2. 2. 3. The Symptom Checklist (SCL 90-R, 1977)
SCL-90-R was developed by Derogatis and Clearly (1977) in order to assess the
symptoms and these symptoms’ severity in preceding one week. Kılıç (1987) translated
it into Turkish and by using 416 university students he found .91 as the internal
consistency value of the scale (Öner, 1997, p.463). Then Dağ (1991) investigated the
psychometric properties of Turkish version of the Symptom Checklist- Revised (SCL-
90-R) by using 532 students from Hacettepe University and reported that SCL-90- R is
a reliable and valid instrument. It includes totally 90 items under 10 subscales
respectively:
1. Somatization (SOM) that consists of 12 items concerning with somatic distress
of the body;
2. Obsessive-Compulsive (O-C) that consists of 10 items related with distress of
unwanted and uncontrollable thoughts and behaviors (compulsions);
3. Interpersonal Sensitivity (INT) consists of 9 items that is associated with
personal distress about feeling inferiority and incompetency when meeting with people;
4. Depression (DEP) consists of 13 items that is related with the distress of
general pessimism, anhedonia, hopelessness, lack of motivation, suicidal ideations and
other cognitive & somatic symptoms;
5. Anxiety (ANX) consists of 10 items that concerns with the distress of high
level of anxiety and irritable mood;
6. Hostility (HOS) consists of 6 items that is related with distress of
aggressiveness, being oppositional, hostile.
7. Phobic Anxiety (PHOB) consists of 7 items that is associated with the distress
of having specific phobia;
8. Paranoid Ideation (PAR) consists of 6 items that is concerning with the
distress of projective thoughts, persecutions, grandiosity feelings and delusions;
9. Psychotism (PSY) consists of 10 items that is related with the distress of
socially introversion, schizoid style of living or having hallucinations or delusions;
10. Additional Items consist of 7 items that are associated with the distress of
sleep and eating disturbances, guilty feelings.
57
SCL-90-R is 5-point Likert type checklist. By asking “how much below
problems or symptoms affected you for last one week?” participants sign the most
appropriate choice based on their conditions (never, a little, half, very much, completely)
and take respectively 0, 1, 2, 3, or 4 scores. For the calculation of the score of each
subscale, total subscale scores are added and are divided into the number of the items in
that subscale. SCL-90-R was used is three ways: Global Symptom Index (GSI), Positive
Symptom Total (PST), and Positive Symptom Distress Index (PSDI). In order to
determine Global Symptom Index (GSI) score, except unanswered ones, all subscale
scores are added, and after total score is found, this score is divided to 90. The possible
score ranged between 0 and 4. For each subscale validity, at least 40% of the checklist
should have been completed. For the interpretation of scores, scores from 0 to 1.5
accepted as normal, scores between 1.51- 2.50 were considered as high distress, scores
between 2.50-4.00 were considered as a very high distress.
Originally Derogatis et al. (1980) found that reliability coefficients of the scale
ranged from .77 to .90 (.86 for SOM subscale, .86 for O-C subscale, .86 for INT
subscale, .90 for DEP subscale, .85 for ANX subscale, .84 for HOS subscale, .82 for
PHOB subscale, .80 for PAR subscale, .77 PSY subscale).
In Dağ (1991) study, test-retest reliability of the scale was found as .90 (n=99),
for each subscale test-retest reliability ranged from .65 to .87, (.75 for SOM subscale,
.87 for O-C subscale, .84 for INT subscale, .87 for DEP subscale, .73 for ANX subscale,
.70 for HOS subscale, .65 for PHOB subscale, .73 for PAR subscale, .79 PSY subscale)
and internal consistency was found as (Cronbach Alpha) .97. Pearson correlation
coefficients between MMPI and SCL-90-R and BDI were .10 - .77 and .78,
respectively. Convergent and discriminant validities were tested by correlations between
SCL-90-R, MMPI, and BDI and it was found as satisfactory. Briefly, results showed
that the SCL-90-R is a reliable and valid instrument for normal university students in
Turkey. Higher scores on this scale indicate greater symptoms. A copy of the Turkish
version was presented in Appendix C.
58
2. 2. 4. State- Trait Anxiety Inventory (STAI, 1970)
STAI is a 40-item self-report scale designed by Spielberger et al. in 1970 in
order to measure the level of state (situational- how a person feels at that moment) and
trait (continual- how a person feels in general independently from any specific situation
or time) anxiety of individuals. It consists of two parts; State and Trait Anxiety
Inventories, and each one consists of 20 items. In practice, state anxiety inventory is
given first, so that the individual could declare her/his anxiety because of seeking help
from mental health professional. In State Anxiety Inventory, by asking “how do you
feel now” to participants, the items are rated on a 4-point scale with 1 standing for not at
all, 2 for a little, 3 for very much, and 4 for completely. In Trait Anxiety Inventory, by
asking "how do you feel in general" to participants, the items are rated on a four-point
scale with 1 standing for almost never, 2 for sometimes, 3 for mostly and 4 for almost
always.
Originally, test-retest reliability of the scale ranged from .16 to .54 for state
anxiety inventory and from .73 to .86 for trait anxiety inventory. The internal
consistency of the former one varied from .83 and .92, and between .86 and .92 for
latter one. Construct and criterion validity values were reported to be satisfactory
(Spielberger et al. 1970).
Öner and Le Comte (1985) performed adaptation study of STAI by examining
both normal and psychiatric patients. Test-retest reliability was found to be ranging .71
to .86 for trait anxiety inventory, from .26 to .68 for state anxiety inventory. Internal
consistency of trait anxiety inventory ranged from .83 to .87, while that of state anxiety
inventory ranged from .94 to .96. Criterion and construct validities were demonstrated
to be satisfactory. A copy of the Turkish version of STAI was presented in Appendix D.
2. 2. 5. Beck Depression Inventory (BDI, 1972)
Depressive symptomatology was assessed by using BDI that is a 21-item self-
report inventory of depression and its levels. It was designed by Beck in 1972.
Participants were asked to circle the most appropriate choice by considering last week.
Each choice has its own score and as a result of these scoring the level of depression is
59
determined. The highest score on this scale is 63. Scores less than 10 refer to no
depression, 11 to 19 mild depression, 20 to 25 to moderate depression, and scores 26
and higher to severely depression.
Beck (1982) found split-half reliability as .74, and Miller & Seligman (1973)
found test-retest reliability as .74. Also, when compared to Hamilton Depression Scale,
validity coefficient was found to be as .75.
In Turkey, Teğin translated BDI into Turkish in 1980 and found test-retest
reliability as .65 on University students. Split-half reliability coefficient was found for
inpatients as .61, for university students as .78. Lastly, Turkish adaptation of BDI has
been developed by Hisli (1998; cited in Şahin & Savaşır, 1997) will be used in the
study. Internal consistency of the Turkish version BDI has been found as .74 and test-
retest reliability coefficient was between .74 and .86 (Şahin & Savaşır, 1997). A copy of
the Turkish version of BDI was presented in Appendix E.
2. 2. 6. Emotion Recognition Test
This computer-based test was constructed by the authors by using a set of
photographs from Ekman & Friesen’s (1976) “Photos of Facial Affect”. It included the
photos of four male and four female models (totally 56 photos) with happy, surprised,
fearful, sad, disgusted, angry, and neutral facial expressions that were selected from
Ekman & Friesen’s (1976) series. The mixed photos were digitized on a computer
presentation via JAVA application developed for the presentation on a portable
computer (ASUS XP 2800 2 Ghz processor, 512 MB main memory, 15” LCD screen
with 1024x768 resolution). It had a trial section that was composed of the first seven
photos. The trial section included every emotional facial expressions (anger, sadness,
happiness, neutral, fear, disgust and surprise) that was presented in the same order for
each participants. Rest of the 49 photos was used for the analyses in the study. There
were equal numbers of happy, sad, surprised, fearful, disgusted, angry, and neutral
expressions overall ensuring that participants did not become familiarized to one
specific emotional category. These 49 photos were presented randomly for each
participant. There were 20-second intervals for each photo. On the monitor, participants
60
saw both photos and colorful seven options in the below of these photos and they were
asked to push the same color button option on the keyboard that match on the monitor.
On the keyboard, D button represents happiness, F button represents sadness, G button
represents fear, H button represents disgust, J button represents anger, K button
represents surprise, and L button represents neutral facial expressions.
2. 3. Procedure
The volunteer inpatients that were under the treatment of alcohol dependence
were asked to participate in the study. Then, they were asked to read and sign the
informed consent form before starting to fill the questionnaires and conducting of
Emotion Recognition Test.
For the control group, predetermined places (courthouses, private schools, and
ordinary cafés) were visited and asked for permission to administer the questionnaires
and Emotion Recognition Test. Differently from experimental group, they were not
asked to fill some questions such as hospitalization number and reasons of drinking in
the demographic information form.
After all participants (N = 101) were assessed with CAGE, SCL-90-R, BDI and
STAI, two groups were administered on an Emotion Recognition Test. All participants
were tested individually in a quiet room. They were instructed to respond as accurately
and as quickly as possible. All stimulus material took approximately 2 or 3 minutes to
complete. Instructions were given in the same way for two groups. No feedback was
given regarding the appropriateness of any response. After completing the
questionnaires and administration of computer based Emotion Recognition Test,
participants were debriefed and thanked for their participation.
2. 4. Data Analyses
All statistical analyses were conducted with the Statistical Package for Social
Sciences for Windows (SPSS) version 13.00. Demographic information was analyzed
through descriptive statistics.
61
For the analyses of Beck Depression Inventory, State-Trait Anxiety Inventory,
Symptom Checklist (SCL-90-R), and CAGE Alcohol Inventory, two-tailed t-test
analyses were applied in order to compare group differences.
In order to examine the decoding accuracy of emotional facial expressions in
both groups, first of all, for each participant the number of correct responses for each
type of facial expression was calculated and an accurately identified expression
received 1 score, and misidentified expression received 0 score. Same procedures were
carried out in order to examine the reaction times; each participant’s
recognition/reaction times toward each expression were calculated. Only accurate
responses were considered for the analysis of reaction times. To sum, each participant
obtained a total reaction time score and a recognition accuracy score. Additional to
these total scores, accuracy scores and reaction times scores toward each facial
expression were also calculated.
A series of 2 (group: dependents vs. non-dependent individuals) *4 (negative
emotional expressions: sadness, fear, anger, disgust) multivariate analysis of variance
(MANOVA) were performed in order to find out group differences in the recognition
accuracy and reaction times. In the analyses of decoding accuracy and reaction times for
happy, surprised and neutral expressions, a series of one-way between subjects
ANOVAs were conducted because of the different natures of emotions.
In order to determine whether there was a group difference on accuracy scores
and general reaction times when depression, state-trait anxiety, and general symptom
distress levels were taken as covariates, a series of one way with covariates between
group designs (ANCOVA) were conducted. To find out the effects of four covariates
(BDI, STAI, SCL-90-R) on each expression, all facial expressions again were analyzed
based on their characteristics. For negative facial expressions 2*4 MANCOVA analysis
was run for the comparison of group differences in the recognition accuracy and reaction
times. For happiness, surprise, and neutral expressions, a series of one-way between
subjects with covariates -ANCOVAs were conducted.
Misinterpretations of emotional facial expressions were found by calculating the
frequencies of each participant’s incorrect responses. The most frequent inaccurate
62
responses were revealed and their percentages were calculated for both groups.
Furthermore, in order to find out whether alcoholism would be predicted by
predictors, we conducted a stepwise multiple analysis.
63
CHAPTER III
RESULTS
First of all, data was examined for missing values, univariate and multivariate
outliers, and 3 cases were deleted. All analyses were carried out by totally 101 cases.
3. 1. Demographic Characteristics of Participants
Based on demographic information form, education levels, marital status,
occupational status, and lastly the duration of alcohol use were determined.
General results revealed that, as illustrated in Table 1 and 2, in terms of
educational level among the all participants (N = 101), 4 individuals (4%) were literate,
27 individuals (26.7%) were graduated from primary school graduated, 23 individuals
(22.8%) were secondary school graduated, 26 individuals (25.7%) had a high school
degree and lastly 21 individuals (20.8%) university graduates.
In terms of occupational status; among the all participants (N = 101), 7
individuals (6.9%) were workers, 45 individuals (44.6%) worked as a state officer, 30
individuals (29.7%) were employers, 15 individuals (14.9%) were retired and finally
only 4 individuals (4%) were unemployed (see Table 2).
Among the all participants (N = 101), 6 individuals (5.9%) were single, 79
individuals (78.2%) were married, 14 individuals (13.9%) were divorced, and 2
individuals (2%) were separated (see Table 2).
Finally, our experimental group (n = 51), in terms of the duration of alcohol use;
their mean is 22 years. Specifically, 23 individuals (46%) reported their use from 10 to
20 years, 20 individuals (40%) reported that from 21 to 30 years, and 7 individuals
(14%) reported more than 31 years (see Table 2).
64
Table 1. Demographic Variables Alcohol Dependence N Mean S.D. t (df)
Age dependent 51 45.49 7.56 -1.013(99) non-dependent 50 46.94 6.79 Education dependent 51 3.29 1.17 -1.276(99) non-dependent 50 3.36 1.22 * p < .001
Table 2. Demographic Variables
N
%
Education
Literate Dependent Non-dependent
1 3
2% 6%
Primary S. Graduation Dependent Non-dependent
16 11
31% 22%
Secondary S. Graduation Dependent Non-dependent
11 12
21% 24%
High School G. Dependent Non-dependent
13 13
25% 26%
Undergraduate or above Dependent Non-dependent
10 11
19% 22%
Occupational Status Worker Dependent Non-dependent
5 2
9.8% 4%
State Officer Dependent Non-dependent
11 34
21.6% 68.4%
Employer Dependent Non-dependent
17 13
33.3% 26%
Retired Dependent Non-dependent
14 1
27.5% 2%
Unemployed Dependent Non-dependent
4 0
7.8% 0
Marital Status Single Dependent Non-dependent
5 1
9.8% 2%
65
Table2.Demographic Variables (Contiuned) n %
Non-dependent 48 96.2% Divorced Dependent Non-dependent
13 1
25.5% 2%
Separated Dependent Non-dependent
2 0
3.9% 0
Alcohol Use in Family
Yes Dependent Non-dependent
8 3
15.7% 6%
No Dependent Non-dependent
43 47
84.3% 94%
Duration of Alcohol Use 10-20 years 23 46% 21-30 years 20 40% ≥ 31 years 8 14%
3. 2. CAGE Alcoholism Inventory, Beck Depression Inventory (BDI), State-Trait
Anxiety Inventory, (STAI) and Symptom Checklist (SCL-90-R) Scores
In order to compare experimental and control group in terms of their depression,
state-trait anxiety, alcohol dependence, and psychopathological symptoms, two-tailed t-
test analyses were conducted on the CAGE, BDI, STAI, and SCL-90-R scores. As
hypothesized, the two groups differed significantly in all measures except state anxiety as
illustrated in Table 3. Inpatients were significantly more alcohol dependent than control
group indicating that CAGE is an appropriate instrument to classify the two groups in
terms of dependency, t (99) = 27.32, p <.001. In terms of BDI scores, the results have
displayed that alcohol dependent individuals obtained significantly higher scores on BDI
than non-dependent individuals, t (99) = 4.340, p <.001; they had significantly higher
trait anxiety levels indicating that these inpatients were generally but not currently more
anxious than control group, t (99) = 4.169, p <.001. Finally they had significantly more
psychopathological symptoms on total psychopathology checklist t (99) = 4.814, p <.001.
As illustrated in Table 5, when 9 subscales of SCL-90-R were considered, results
revealed that alcohol dependent group significantly scored higher on all subscales; t-test
66
values were respectively; for somatization t (99) = 3.657, p < .001; for obsessive thoughts
t (99) = 4.867, p < .001; for interpersonal sensitivity t (99) = 4.052, p < .001; for
depression t (99) = 3.926, p < .001; for anxiety t (99) = 2.898, p < .001; for hostility t (99)
= 2.898, p < .05; for phobic anxiety t (99) = 5.213, p < .001; for paranoid thoughts t (99)
= 3.075, p < .05; and finally for psychotism t (99) = 5.036, p < .001. In other words,
alcohol dependent individuals have had significantly more discomfort on these nine
subtypes than non-dependent individuals (see Table 4).
Table 3. Descriptive Statistics of BDI, STAI, CAGE and SCL-90-R Results Measures Alcohol
Dependence N Mean
SD t-test (df)
BDI Dependent 51 13.96 7.94 4.340(99)* Non-dependent 50 7.72 6.40 Total 101 10.87 7.84 STAI-S Dependent 51 37.58 9.02 1.639(99)* Non-dependent 50 34.68 8.80 Total 101 36.14 8.99 STAI-T Dependent 51 46.52 8.25 4.169(99)* Non-dependent 50 40.08 7.26 Total 101 43.33 8.39 CAGE Dependent 51 3.49 .78 27.32(99)* Non-dependent 50 .12 .35 Total 101 10.87 1.80 SCL-90-R Dependent 51 73.50 52.35 4.814(99)* Non-dependent 50 33.28 27.36 Total 101 53.59 46.41 * p < .001
67
Table 4. Descriptive Statistics of Subscales of SCL-90-R Results Subscales of SCL-90-R
Alcohol Dependence
N Mean
SD t-test (df)
Somatization Dependent 51 8.45 7.81 3.657(99)** Non-dependent 50 3.76 4.65 Total 101 6.12 6.83 Obs.Com. Dependent 51 10.37 7.07 4.876(99)** Non-dependent 50 4.66 6.83 Total 101 7.54 6.52 Inter.Sens. Dependent 51 8.60 11.43 4.082(99)** Non-dependent 50 4.42 3.76 Total 101 6.53 5.54 Depression Dependent 51 11.84 9.30 3.926(99)** Non-dependent 50 5.92 5.26 Total 101 8.91 8.10 Anxiety Dependent 51 6.74 6.63 3.768(99)** Non-dependent 50 2.76 3.38 Total 101 4.77 5.62 Hostility Dependent 51 3.66 3.92 2.898(99)* Non-dependent 50 1.82 2.22 Total 101 2.75 3.31 Phobia Dependent 51 4.17 3.92 5.213(99)** Non-dependent 50 1.02 1.72 Total 101 2.61 3.41 Paranoia Dependent 51 5.81 4.71 3.075(99)* Non-dependent 50 3.46 2.90 Total 101 4.67 4.08 Psychotism Dependent 51 6.74 6.63 5.036(99)** Non-dependent 50 2.76 3.38 Total 101 4.77 5.62 ** p < .001, * p < .01 3. 3. Decoding Accuracy in General
Decoding accuracy was defined as the participants’ ability to infer the presented
emotion correctly on the monitor. An accurately identified expression received 1 score,
misidentified expression received 0 score. Each participant had his own total scores. To
investigate whether there was the group differences on accuracy scores, one way
ANOVA was run with group on total accuracy scores. The results indicated that
although the mean scores of non-dependent individuals were higher than alcohol
dependent individuals, they did not differ significantly from each other in terms of
68
accurate recognition toward scores of all seven-expression scores. In other words, it was
found that alcohol dependent individuals did not perceive the expressions significantly
worse than non-dependent individuals. F (1, 99) = 3.34, p > .05 (ns.) (see Table 5 and
6).
Table 5.ANOVA Results of Recognition of Accuracy Sum of Squares df Mean Square F Sig. Between Gr. 161.33 1 161.33 3.34 Within Gr. 4789.83 99 48.38 Total 4951.16 100
.071
Table 6. Descriptive Statistics of Accuracy Scores toward all Emotional Expressions Alcohol Dependence N Mean SD Accuracy Scores dependents 51 32.39 7.41 non-dependents 50 34.92 6.45 Total 101 33.64 7.03
3. 3. 1. Decoding Accuracy of Each Facial Expression
In order to assess whether there was a group difference between alcohol
dependent individuals and control participants’ performances in their ability to decode
emotional facial expression, a between subject multivariate analysis of variance
(MANOVA), 4 (negative facial expressions: anger, sadness, disgust, fear) * 2 (group:
alcohol dependent individuals vs. control) was carried out. The results showed that
according to Wilks’ Lambda criterion, these 4 expressions were significantly affected by
group, F (4, 96) = 3.50, p < .05. Surprisingly, univariate analyses demonstrated that
alcohol dependent individuals and non-dependent individuals did not differ from each
other in the recognition of angry, fearful, and sad expressions. The only significant
difference was observed in the recognition of the expression of disgust. F(1, 99) =
10.424, p .< .05. As presented in Table 7, alcohol dependent individuals had lower
accuracy scores in the recognition of disgusted expressions than other expressions when
69
compared to non-dependent individuals.
Accuracy scores for happy (a positive emotion), neutral and surprised (neither
positive nor negative emotions) were treated separately because of their different nature
from negative emotions; they were analyzed by univariate analysis of variance (One-Way
ANOVA). As expected, findings have suggested that no expression exhibited a
significant difference between groups (see Tables 7, 8, 9, 10, 11).
In sum, it was found that the performances of alcohol dependent inpatients were
similar to control group’s performances in the recognition of six expressions- happy, sad,
angry, surprised, and neutral faces. Surprisingly, the results displayed that true scores of
alcohol dependent individuals towards fearful faces were higher than the scores of control
group. However, this difference did not reach a statistical significance (see Table 7).
Table 7. Descriptive Statistics of Accuracy Scores towards Negative Emotional Expressions Facial Expressions
Alcohol Dependence
N Mean
S.D Univariate F (1,99)
Angry Dependents 51 4.68 1.66 n.s Non-dependent 50 4.90 1.63 Total 101 4.79 1.64 Fearful Dependents 51 3.00 1.57 n.s Non-dependent 50 2.72 1.77 Total 101 2.86 1.67 Disgusted Dependents 51 4.01 1.81 10.42*
Non-dependent 50 5.14 1.66 Total 101 4.57 1.82 Sad Dependents 51 4.23 1.97 n.s Non-dependent 50 4.72 1.75 101 4.47 1.87 * p < .05
70
Table 8. Descriptive Statistics of Accuracy Scores towards the Expressions of Happiness, Surprise, and Neutral
EFE Alcohol Dependence
N Mean
S.D
Happiness Dependent 51 6.78 .576 Non-dependent 50 6.82 .481 Total 101 6.80 .529 Surprise Dependent 51 5.33 1.43 Non-dependent 50 5.68 1.30 Total 101 5.50 1.37 Neutral Dependent 51 4.33 2.46 Non-dependent 50 4.94 1.94 Total 101 4.63 2.30
Table 9.ANOVA Results of Happy Emotional Expressions Sum of Squares df Mean Square F Sig. Between Gr. .032 1 .032 .114 Within Gr. 28.07 99 .283 Total 28.04 100
.737
Table 10.ANOVA Results of Surprised Emotional Expressions Sum of Squares df Mean Square F Sig. Between Gr. 3.03 1 3.03 1.613 .217 Within Gr. 186.21 99 1.88 Total 189.25 100
Table 11. ANOVA Results of Neutral Expressions
Sum of Squares df Mean Square F Sig. GROUP 9.292 1 9.292 1.885 .173 Error 488.15 99 4.93 Total 2666.0 101
a R Squared = .019 (Adjusted R Squared = .009)
71
3. 4. Manual Reaction/Recognition Times for Accurate Responses in General
Due to investigate whether there was a group difference on reaction times
toward all accurately recognized expressions, one way ANOVA was run with group
(dependents vs. non-dependent individuals) on total reaction time scores. Unexpectedly
statistical analysis did not manifest any significant differences between alcohol
dependent individuals and non-dependent individuals in terms of reaction times towards
all seven expressions. In other words, alcohol dependent individuals did not react
quicker or slower toward expressions than non-dependent individuals, F (1, 99) = 2.20,
p > .05 (ns.) (see Table 12).
Table 12. ANOVA results of Reaction Times towards all Expressions
Sum of Squares df Mean Square F Sig. GROUP 9625663785 1 9625663785 2.203 .141 Error 432518541237 99 4368874153 Total 3210788526867 101
a R Squared = .022 (Adjusted R Squared = .012)
3. 4. 1. Reaction Times for Accurate Responses towards Each Facial Expression
In order to find out the group differences on the reaction times towards negative
expressions, a multivariate analysis of variance (MANOVA) was conducted on 4
negative expressions (anger, fear, disgust and sadness). The findings displayed that
alcohol dependent individuals did not perform significantly different from non-
dependent individuals in any of the negative expressions (see Table 13). According to
Wilks’ Lambda criterion, F (4, 96) = .872, p . > .05 (ns.).
72
Table 13. Descriptive Statistics of Reaction Times towards Negative Expressions Reaction Times Alcohol
Dependence N Mean
(seconds) SD
RT Sadness Dependent 51 24.36 17.29 Non-dependent 50 27.33 20.04 Total 101 25.83 18.67 RT Fear Dependent 51 17.83 14.36 Non-dependent 50 18.09 15.55 Total 101 17.96 14.87 RT Anger Dependent 51 24.96 14.00 Non-dependent 50 30.87 22.45 Total 101 27.89 18.81 RT Disgust Dependent 51 21.74 10.85 Non-dependent 50 24.60 13.41 Total 101 23.16 12.21
For examining the reaction times towards happy, neutral, and surprised
expressions, each of facial expressions was calculated separately on univariate analysis
of variance (One way ANOVA). As expected, no significant results were found between
alcohol dependent individuals and non-dependent individuals in terms of the reaction
times toward happy, surprised, and neutral expressions. F(1, 99) = .319, p . > .05 (ns.);
F(1, 99) = .569, p . > .05 (ns.); F(1, 99) = .1.620, p . > .05 (ns.) respectively (see Tables
14, 15, 16, 17).
Table 14. ANOVA results of Reaction Times towards Happy Expressions Sum of Squares df Mean Square F Sig. Between Gr. 124930496.9 1 124930496.9 .319 Within Gr. 38736661107.3 99 391279405.1 Total 38861591604.3 100
.573
73
Table 15. ANOVA results of Reaction Times towards Surprised Expressions Sum of Squares df Mean Square F Sig. Between Gr. 74694218.6 1 74694218.6 .569 Within Gr. 13001339299.3 99 131326659.5 Total 13076033517.9 100
.453
Table 16. ANOVA results of Reaction Times towards Neutral Expressions Sum of Squares df Mean Square F Sig GROUP 324358034 1 324358034 1.620 .206 Error 00.853 99 200214387 Total 65110990639 101
a R Squared = .016 (Adjusted R Squared = .006)
Table 17. Descriptive Statistics of Reaction Times toward the Expressions of Happiness, Neutral and Surprise Reaction Times Alcohol
Dependence N Mean
(seconds) SD
RT Happiness Dependent 51 22.74 9.18 Non-dependent 50 24.91 26.54 Total 101 23.84 19.71 RT Neutral Dependent 51 19.32 13.41 Non-dependent 50 22.90 14.86 Total 101 21.09 14.19 RT Surprise Dependent 51 24.91 11.43 Non-dependent 50 26.63 11.48 Total 101 25.76 11.44
3. 5. Covariates with Accuracy Decoding in General
In order to examine whether there was a group difference on accuracy scores
when depression, state-trait anxiety and general symptom distress levels were taken into
the account, one-way variance analyses with covariates between group design
(ANCOVA) was conducted with group (dependents vs. non-dependent individuals) and
covariates as BDI, STAI and SCL on total accuracy scores. The findings yielded that no
significant difference was observed. F (1, 95) = 1.50, p > .05 (ns.) (see Table 18).
74
Covariates did not cause any significant differences on the recognition of all facial
expression scores.
Table 18. ANCOVA Results of Accuracy Decoding Measures Sum of Squares df Mean Square F Sig. SCL-90-R 38.65 1 38.65 .789 .377 SAI 31.65 1 31.65 .646 .424 TAI 55.62 1 55.62 1.135 .289 BDI 35.63 1 35.63 .727 .396 GROUP 73.350 1 73.350 1.497 .224 Error 4653.3 95 48.98
a R Squared = .060 (Adjusted R Squared = .011)
3. 5. 1. Covariates with Decoding Accuracy in Each Facial Expression
Group differences for the accuracy of 4 negative emotions: fear, disgust, anger,
sadness were examined by taking the scores Beck Depression Inventory (BDI), State-
Trait Anxiety (STAI), and Symptom Checklist (SCL-90-R) as the covariates. Results of
MANCOVA revealed significant group differences. On the basis of Wilks’ Lambda
criterion F (4,92) =5.35, p.< .001. As presented in Table 19, however, analyses indicated
that alcohol dependent group had lower accuracy scores than non-dependent group only
for the recognition of disgusted expression, F (1,95) = 12.32, p.< .01.
The separate analyses of one way with covariate design (ANCOVA) for the
recognition of happy, surprised, and neutral expressions have exhibited that groups did
not differ from each other when trait and state anxiety, depressive symptomatology and
general psychopathological distress were considered as covariates. In other words,
accuracy of other emotions did not indicate a significant group differences, F values
respectively; F (1,95) =.161, p. > .05 (ns.); F (1,95) = .828, p. > .05 (ns.); F (1,95) =
7.69, p. > .05 (ns.).
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Table 19. MANCOVA with Decoding Accuracy in Each Facial Expression
Measures Dependent V. Sum of Squares df Mean Square F Sig. SAI
SAD 3.517 1 3.517 .988 323 FEAR 3.947 1 3.947 1.419 236
ANGER .099 1 .099 .037 .849 DISGUST .084 1 .084 .028 .867 TAI SAD .567 1 .567 .159 .691 FEAR 2.416 1 2.416 .869 .354 ANGER 10.728 1 10.728 3.994 .049
DISGUST 4.448 1 4.448 1.477 .227 BDI SAD .808 1 .808 .227 .635 FEAR 3.714 1 3.714 1.335 .251 ANGER .009 1 .009 .003 .955 DISGUST 2.586 1 2.586 .859 .356 SCL-90-R SAD .755 1 .755 .21 .646 FEAR .037 1 .03 .013 .909 ANGER 2.281 1 2.281 .849 .359 DISGUST 4.378 1 4.378 1.454 .231 GROUP SAD 4.643 1 4.643 1.305 .256 FEAR 8.105 1 8.105 2.914 .091
ANGER .013 1 .013 .005 .945 DISGUST 37.108 1 37.108 12.322 .001*
Error SAD 338.075 95 3.559 FEAR 264.218 95 2.781 ANGER 255.145 95 2.686 DISGUST 286.096 95 3.012 Total SAD 2374.000 101 FEAR 1107.000 101 ANGER 2590.000 101 DISGUST 2446.000 101
* p < .01
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3. 6. Covariates with Manual Reaction Times for Accurate Responses
In order to find out any group difference on general reaction times toward
accurately recognized expressions by taking the scores of Beck Depression Inventory
(BDI), State-Trait Anxiety (STAI), and Symptom Checklist (SCL-90-R) as the
covariates, one-way univariate analysis with covariates (ANCOVA) was conducted.
However, this analysis did not reveal any significant findings, F (1,95) = 1.905, p. > .05
(ns.)
3. 6. 1. Covariates with Reaction Times for Accurate Responses towards Each
Facial Expression
Due to prove the effect of state-trait anxiety, depression level, and general
psychopathology scores on reaction times toward each expression, firstly a multivariate
analysis with covariances (MANCOVA) was conducted. Multivariate analysis of 2
(group: dependents vs. controls) * 4 (negative emotions: fear, disgust, anger, sadness)
between group design with covariates as STAI, BDI and SCL-90-R was carried out. As
illustrated in Table 20, the results manifested that alcohol dependent group differed
significantly from non-dependent group only in the recognition time of disgusted faces,
Wilks’ Lambda criterion F (1,95) = 4.289, p. < .05. In other words, alcohol dependent
group recognized disgusted expression significantly faster than non-dependent
individuals.
As predicted, the results of separate univariate analyses with the same covariates
(ANCOVA) for the recognition time of happy, surprised and neutral expressions yielded
that alcohol dependent group did not differ significantly from non-dependent group, F
(1,95) = .541, p. > .05 (ns.); F (1,95) = .925, p. > .05 (ns.); F (1,95) = 1.555, p. > .05
(ns.) respectively.
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Table 20. MANCOVA with Reaction Times for Accurate Responses towards Each Negative Facial Expressions
Measures DV Sum of Squares df Mean Square F Sig.
State Anxiety
RT Sad 29597151.1 1 29597151.1 .084 .773
RT Fear 54020495.1 1 54020495.1 .237 .628 RT Anger 483183705.9 1 483183705.9 1.378 .243 RT Disgust 230652923.3 1 230652923.3 1.571 .213 Trait Anxiety
RT Sad 835960005.4 1 835960005.4 2.367 .127
RT Fear 236971463.4 1 236971463.4 1.038 .311 RT Anger 135484868.6 1 135484868.6 .386 .536 RT Disgust 8046209.2 1 8046209.2 .055 .815 BDI RT Sad 374122208.0 1 374122208.0 1.059 .306 RT Fear 27168709.6 1 27168709.6 .119 .731 RT Anger 19168517.3 1 19168517.3 .055 .816 RT Disgust 265481125.0 1 265481125.0 1.809 .182 SCL-90-R RT Sad 20129804.5 1 20129804.5 .057 .812 RT Fear 2712591.0 1 2712591.0 .012 .913 RT Anger 4105242.5 1 4105242.5 .012 .914 RT Disgust 61053171.0 1 61053171.0 .416 .521 GROUP RT Sad 199821735.8 1 199821735.8 .566 .454 RT Fear 48366281.9 1 48366281.9 .212 .646 RT Anger 315380593.0 1 315380593.0 .899 .345 RTDisgust 629605221.2 1 629605221.2 4.289 041* ERROR RT Sad 33553524302.1 95 353194992.6 RT Fear 21679128275.5 95 228201350.2 RT Anger 33318829809.9 95 350724524.3 RT Disgust 13944454432.6 95 146783730.8 * p <.05. a. R Squared = .038 (Adjusted R Squared = -.013 b. R Squared = .020 (Adjusted R Squared = -.031) c. R Squared = .058 (Adjusted R Squared = .009. d. R Squared = .065 (Adjusted R Squared = .016)
78
3. 7. Misinterpretations of Emotional Facial Expressions
In our study, we aimed to find out a group difference in the recognition of facial
expressions between alcohol dependent and non-dependent group. Namely, we expected
that alcohol dependent group would have less accuracy scores than non-dependent
group. However, our results failed to reveal an accuracy deficit in the identification of
happy, sad, fearful, disgusted, surprised, and neutral expressions except disgusted ones
in alcohol dependent group. Therefore, we decided to concentrate on the number of
inaccurate responses of both groups in order to find out the existence of common
misinterpretations of facial expressions (see Table 21). The total scores of accurate
responses were higher than the scores of inaccurate responses of both groups. Moreover,
general accurate scores of non-dependent individuals ranged from 39% (fear) to 88%
(happy).
As expected, the findings have suggested that both alcohol dependent and non-
dependent groups recognized happy faces more accurately than other expressions at 87%
and 88% respectively. Additionally, it was obtained that two groups tended to display
same misjudgments toward fearful, angry, surprised, and neutral faces except sad and
disgusted faces.
Firstly, the analyses demonstrated that there was a significant difference between
alcohol dependent group and non-dependent group in the recognition of disgusted
expressions. Alcohol dependent individuals recognized disgusted faces at the ratio of
58%. The rest, 42%, inaccurately responded to the disgusted faces, and 46% of this
percentage (42%) perceived the expression of disgust as anger. On the other hand, in the
group of non-dependent individuals, the ratio of properly understanding was 74%.
Within the incorrect responses (26%), 36% of them failed to perceive disgusted
expression and they misunderstood them as surprised ones. This difference may be
explained by the effect of alcohol abuse.
In terms of sad expressions, 68% of control group responded accurately. When
we consider their inaccuracy scores, it was found that non-dependent group perceived
sadness as neutral in the rate of 36%. However, differently from non-dependent
79
individuals, 60% of alcohol dependent individuals decoded sadness correctly and they
tended to misjudge sad faces as surprised faces with the percentage of 35%.
The results exhibited that 70% of non-dependent group evaluated angry faces
properly, whereas this ratio declined to 67% for alcohol dependent group. When we
focused on their incorrect responses, it was obtained that 33% of alcohol dependent
individuals and 32% non-dependent individuals misevaluated angry faces as surprised
faces.
Similarly, it was observed that 69% of non-dependent individuals judged neutral
faces exactly however this rate decreased to 62% for alcohol dependent individuals. In
addition, both groups misinterpreted neutral faces as sad faces. Their inaccurate response
rates were 34% in the group of non-dependent individuals and 36% in the group of
alcohol dependent individuals.
Interestingly, the findings postulated that non-dependent individuals recognized
fearful faces with the minimum scores when compared to all emotional faces. Their
percentage of correct responses was only 39%. This ratio was higher for alcohol
dependent individuals as 42%. When we consider their misjudgments, it was revealed
that both groups tended to misinterpret fearful faces as surprised faces. The inaccurate
response rates were 65% in non-dependent individuals and 63% in alcohol dependent
individuals. In terms of surprised expression, control group seemed to get the highest
score except happy with the ratio of 82%. Just like non-dependent individuals, the
accuracy scores of alcohol dependent group were also higher. Their percentage of
accuracy scores was 77%. Moreover, two groups’ error rates were the same. In both
groups, 51% of inaccurate responses exhibited that alcohol dependent and non-
dependent individuals tended to perceive surprised faces as fearful faces.
These shared misinterpretations of facial expressions in alcohol dependent and
non-dependent groups could be associated with cultural factors. These findings would be
discussed in the next chapter.
80
Table 21. Descriptive Statistics of Accurate Responses of All Participants towards All Emotional Expressions
EFE Alcohol
Dependence N % Mean SD Min. Max.
Happiness Dependent 51 87 6.78 .576 4 7 Non-dependent 50 88 6.82 .418 5 7 Total 101 6.80 .052 Sadness Dependent 51 60 4.23 1.75 0 7 Non-dependent 50 68 4.72 1.97 1 7 Total 101 4.47 1.82 Fear Dependent 51 42 3.00 1.77 0 5 Non-dependent 50 39 2.72 1.57 0 7 Total 101 2.86 1.67 Anger Dependent 51 67 4.68 1.66 1 7 Non-dependent 50 70 4.90 1.63 1 7 Total 101 4.79 1.64 Surprise Dependent 51 77 5.33 1.43 0 7 Non-dependent 50 82 5.68 1.30 2 7 Total 101 5.50 1.37 Disgust Dependent 51 58 4.01 1.81 0 7 Non-dependent 50 74 5.14 1.66 0 7 Total 101 4.57 1.82 Neutral Dependent 51 62 4.33 2.46 0 7 Non-dependent 50 69 4.94 1.94 0 7 Total 101 4.57 2.23
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3. 8. Stepwise Regression Analysis
In order to estimate whether alcohol dependence on the basis of CAGE scores
would be predicted by demographical variables such as age and education; by
psychological symptoms scores obtained from Beck Depression Inventory, State-Trait
Anxiety Inventory, and Symptom Checlikst and its nine subscales-anxiety, depression,
phobic anxiety, hostility, interpersonal sensitivity, obsessive-compulsion, somatization,
psychotizm, and paranoid ideation; by recognition scores from each seven emotional
facial expressions; and lastly by reaction time scores toward accurately recognized facial
expressions, a stepwise multiple regression analysis was run. CAGE scores were entered
as the Dependent Variable. The results of stepwise multiple regression analyses were
presented in Table 24, including multiple R (R), R square (R2), adjusted R2 (∆R2), the
standardized regression coefficients-Beta (β), semipartial correlations (sp²) and t values.
In the first step, age and educational levels of both groups were submitted;
however, they did not predict a significant degree of variance in the alcohol dependence.
In the next step, BDI, STAI, and SCL-90-R scores were entered and the results revealed
that only obsessive-compulsion, Beck Depression Inventory (BDI), State-Trait Anxiety
Inventory State Form (STAI-S) scores predicted alcohol dependence significantly, R2=
.22, F (1,99) = 27.716, p. < .001; R2= .25, F (2,98) = 16.555, p. < .001; R2= .28, F (3,97)
= 12.765, p. < .001 respectively. Findings indicated that %22 of variance in alcohol
dependence or CAGE scores was explained by obsessive-compulsion characteristics of
participants; %25 of variance in alcohol dependence was explained by depression scores;
%28 of variance in alcohol dependence was accounted for state anxiety scores of groups.
In the third step, accuracy scores from seven emotional facial expressions were submitted
due to predict alcohol dependence. The results suggested that accurate scores in the
recognition of disgusted and fearful faces predicted alcohol dependence significantly,
R2= .33, F (4,96) = 11.998, p. < .00; R2= .37, F (5,95) = 11.247, p. < .001 respectively
(see Table 25). In the last step, reaction time scores were submitted whether they would
predict alcohol dependence, nevertheless, the findings did not demonstrate an association
between reaction times and CAGE scores.
In sum, stepwise regression analyses indicated that obsessive-compulsive subscale
82
in other words, distress of unwanted and uncontrollable thoughts and behaviors
(compulsions), depression level obtained from Beck Depression Inventory, and
recognition of fearful facial expressions predicted positively the existence of alcoholism.
Nevertheless, recognition accuracy scores of disgusted facial expression and scores from
State Anxiety Inventory predicted negatively the presence of alcohol dependence on the
basis of CAGE.
Table 22. Variables in each step for Stepwise Multiple Regressions using Demographics, BDI, STAI, SCL-90, Facial Expressions and Reaction Times to predict Alcoholism Level Variables
Step I Age Education Step II STAI BDI 9 subscales of SCL-90-R Step III 7 Facial Expressions Step IV Reaction Times to 7 Facial Expressions Dependent Variable Scores on CAGE Alcoholism Inventory
83
Table 23. Summary of Stepwise Multiple Regressions using demographics, BDI, STAI, SCL-90, Recognition of Facial Expressions due to predict alcohol dependence based on CAGE Model R R² ∆R²
(Adjusted) Β (Beta)
sp² (semi-partial)
t
1. Obs-Com. .468 .22 .21 .47 .47 5.25***
2. Obs.Com., BDI
.503 .25 .23 .33 .23
.30 .21
3.058** 2.106*
3. Obs. Com., BDI, State Anxiety
.532 .28 .26 .38 .34 -.23
.33 .28 -.20
3.465** 2.841** -.2032*
4. Obs. Com., BDI, State Anxiety, Disgust
.577 .33 .31 .34 .35 -.20 -.23
.31 .30 -.19 -.27
3.187**
3.020**
-1.856 -2.690**
5. Obs. Com., BDI, State Anxiety, Disgust, Fear
.610 .37 .33 .34 .35 -.20 -.27 .20
.32 .33 -.21 -.32 .24
3.187**
3.020** -1.856
-3.243**
2.415*
* p < .05., ** p < .01, *** p < .001.
84
CHAPTER IV
DISCUSSION
4. 1. Alcohol Dependence and Co-morbid Disorders
One of the purposes in our study was to measure the levels of depression, state-
trait anxiety, the existence of alcoholism, and the presence of general
psychopathological distress of both groups (nine subscales -anxiety, depression, phobic
anxiety, hostility, interpersonal sensitivity, obsessive-compulsion, somatization,
psychotizm, and paranoid ideation). Most of the studies up to now have shown that
anxiety disorders and depression are associated with high rates of alcohol dependence
both in nonclinical and clinical populations even though the exact nature of these
associations remains unclear (e.g. Gratzer et al., 2004; Ceylan & Turkcan, 2003, p.59-
63; Nolen-Hoeksema, 2004; Hoes, 1997; Merikangas et al., 1998; Wetterling and
Junghanns, 2000; Preisig et al., 2001; Devanand, 2002; Tedstone & Coyle, 2004; Terra
et al., 2006). It was observed that in the alcohol dependence population, the probability
of developing of a unipolar mood disorder is four times more than healthy population
(Ceylan, Turkcan, 2003, p.63). In addition, Ceylan, Turkcan suggested that alcohol
dependence is accompanied with mostly agoraphobia, social anxiety and PTSD among
all anxiety disorders (2003, p. 63). A prevalence of 30.6% was found for specific phobia,
24.7% for social phobia, 22.2% for anxiety disorder induced by alcohol, 19.3% for
generalized anxiety disorder, 5% for obsessive-compulsive disorder, 4.6% for
posttraumatic stress disorder, and 2% for panic disorder with agoraphobia (Terra et al.,
2006). Merikangas et al. (1998) who investigated co-morbidity between specific
subtypes of anxiety and alcoholism postulated that the association was greater for phobic
disorders than for panic and generalized anxiety disorder. In the study of Gratzer et al.
(2004), their findings exhibited that a significantly higher rate of alcoholism was linked
to depression-anxiety rather than only anxiety.
85
In accordance with previous studies, the results of this study yielded that alcohol
dependent group scored higher than normal control group on the CAGE Alcohol
Inventory, Beck Depression Inventory, Trait Anxiety Inventory, and Symptom Checklist
(SCL-90-R) and on its nine subscales. However, no significant difference was found in
State Anxiety Inventory between our experimental and control group. Thus, as expected,
alcohol dependent individuals were found as more depressed, had higher scores of
psychopathological distress in terms of nine measures, and had higher trait anxiety than
non-dependent individuals.
4. 2. Decoding Accuracy of Emotional Facial Expressions
In our study, it was predicted that alcohol dependent individuals would have
cognitive impairments in the recognition of universal Emotional Facial Expression
(EFE) -happy, sad, angry, disgusted, fearful, surprised, and neutral expressions.
However, the results indicated that there was no significant difference between alcohol
dependent individuals and non-dependent individuals in the total accurate recognition
scores toward seven expressions-happiness, sadness, fear, anger, disgust, surprise, and
neutral. Even though alcohol dependent individuals did more errors in the total accuracy
scores than non-dependent individuals did, this difference did not reach a statistical
significance. On the other hand, their pattern of answers to emotional expressions differs
from each other. The findings revealed that alcohol dependent individuals and non-
dependent individuals did not differ from each other in their recognition of happiness,
sadness, fear, anger, surprise, and neutral except disgusted faces. In other words, alcohol
dependent individuals did more errors in their recognition of disgusted expression
significantly, than control participants did. Additionally, the findings also suggested that
alcohol dependent individuals perceived disgusted faces as angry faces. Almost half of
the inaccurate responses showed that they misinterpreted the expression of disgust as
angry.
Interestingly, even though there was not any significant difference between two
groups in terms of the number of accurate responses, alcohol dependent individuals were
found as better in the recognition of fearful expression than non-dependent individuals.
86
Non-dependent individuals did more errors than alcohol dependent individuals in the
decoding of fearful faces. These inaccurate response tendencies will be discussed in Part
4.6.
In sum, although our study failed to manifest total accuracy deficit between
experimental and normal control groups, some of the results were in line with previous
studies showing a deficit in the recognition of emotional expression in alcohol
dependent individuals with a particular bias in disgust and their misinterpretation of
disgusted expression as angry. The findings of Philippot et al. (1999) exhibited that
recognition of facial expressions seemed to be severely impaired in recovering
alcoholics. The authors suggested that particularly alcohol dependent individuals had a
bias in their recognition of angry and contempted faces. In other words, it was found
that alcohol dependent participants had a systematic bias in interpreting faces
expressing disgust as anger or contempt similar to our findings.
Furthermore, Townsend and Duka (2003) postulated that alcohol dependent
inpatients tended to perceive angry faces when they were shown to disgusted faces. This
result suggests that alcohol dependent individuals may have a difficulty in
distinguishing these two emotional expressions. It was also found that alcohol
dependent individuals also overestimated the pictures of disgust when compared to
angry ones. Townshend and Duka (2003) were not able to clarify this finding; at last,
they interpreted this confusion as the damage of long-term alcohol abuse. They
concluded that in the processing of anger and disgust, orbitofrontal cortex plays a
remarkable role. These authors suggested that there might have been a reduction in the
functioning of these critical areas. However, even though alcohol has deleterious effects
on brain functioning, there has not been any distinct explanation yet for the impairment
of facial expressions. Nevertheless, our findings highlight that alcohol dependent
individuals seem to be more sensitive to the feelings of threat on the faces looking at
them and they are more likely to interpret those facial expressions as hostile rather than
disgusted or angry.
87
4. 3. The Effects of Depression, State-Trait Anxiety, and Psychopathological
Symptoms on the Decoding Accuracy of Emotional Facial Expressions
In particular, previous studies have indicated that there is a general tendency to
find emotion-congruent effects when people interpret the ambiguity. That is, if an
individual experiences a negative emotion, s/he is more likely to adopt the negative
interpretation of an ambiguous stimulus than other individuals. For instance, anxiety is
known to be associated with biases towards threat related information and with a bias
towards the threatening interpretation of ambiguous stimuli. In other words, it was
observed that anxious individuals selectively perceived threatening information such as
misunderstanding of negative emotions and depressed individuals having a bias for
information related to sad expression. Based on this assumption, in this study, we
expected alcohol dependent individuals to display both attentional and evaluative biases
towards negative emotional expressions because of their higher levels of depression and
higher scores on trait anxiety. Also, by taking these symptoms as covariates, we
attempted to take out their roles in the information processing system. However, our
findings yielded that when state-trait anxiety level, depression level and nine
psychopathological symptoms were taken as covariates, alcohol dependent individuals
had impairment only in the recognition of the expression of disgust. This finding can be
interpreted by explaining the nature of the emotion of disgust.
Disgust is one of the basic emotions, which is characterized by a distinctive
facial expression, specific cognitive, physiological, and behavioral components. It has an
evolutionary dimension and it motivates behavior leading to an avoidance of infection
(Rubio-Godoy et al., 2007). It was observed that even in primates, bitter stimuli elicit
disgusted expression like as three-day-old baby displays disgusted when a stinky odor
was added to breast milk (Erickson and Schulkin, 2003). As can be seen, emotional
expressions serve a communicative role that human beings and animals use in order to
survive. By means of the emotional expression of disgust, animals learn to give aversive
responses from a poisonous food. Therefore, a communicative and social function of
emotional expressions causes animals to learn what is safe to eat by observing others’
reactions to food. As far as it is known, chronic alcohol consumption leads to brain
88
dysfunction that makes individuals suffer from learning and especially spatial memory
impairments (Chelune and Parker, 1981; Obernier et al., 2002). It was found that in the
limbic system, septal area takes a major role in emotionally significant learning, such as
avoiding aversive experiences. Similar to the interpretations of Townshend and Duka,
perhaps the toxic effect of alcohol may decrease the related functioning of brain.
One possible explanation about the confusion of disgusted expressions with
angry ones may include the morphological characteristics of two expressions rather than
decreased functioning of brain areas. In terms of appearance characteristics, anger is the
emotion most often confused with disgust (Ekman, 2003, p.184). Both have the lowered
eyebrows. Also, anger is usually masked except anger-disgust expression. However,
while looking at closely, there are much more differences than similarities. For instance;
eyebrows are not drawn together, upper eyelids are not raised, eyelid muscles are not
tense in disgusted faces. Upper lip is raised in disgusted faces like u shape however, in
angry expression, lips are pressed together (narrowing the lips).
Furthermore, there has been a growing interest in the role of disgust in
psychopathology especially among anxiety disorders, such as Obsessive-Compulsive
Disorder-fear of contamination and Specific Phobias, even in Eating Disorders-food
rejection (Davey et al., 2006; Rossignol et al., 2007).
Our research has failed to show the effect of state-trait anxiety on the
identification of all emotional expressions. Our results are not consistent with those
already reported in the literature that especially social anxious people show evaluative or
attentional bias towards the processing of social threat. Because angry expression is
universally assumed as the salient signal of threat and danger, numerous findings
revealed that sub-clinically or clinically anxious individuals misinterpret angry
expression (Surcinelli et al., 2006; Ioannou et al., 2004; Rossignol et al., 2007).
However, there are also contrary findings in the literature. For instance, Mohlman et al.
(2007) found that anxious individuals recognized the expression of anger more easily
and accurately than other expressions. On the other hand, Philippot and Douilliez (2005)
demonstrated that individuals with generalized anxiety disorder, social phobia, panic
disorder with agoraphobia, obsessive-compulsive disorder did not exhibit any attentional
89
or evaluative biases in the process of threatening facial expressions. When we consider
the previous studies, it is difficult to draw clear-cut conclusions about evaluative or
attentional bias in anxiety.
Similarly, we hypothesized that when Beck Depression Inventory (BDI) scores
were accepted as covariates, alcohol dependent group would show more evaluative bias
(misinterpretation) especially toward negative expressions when compared to normal
control group. However, we did not find any significant differences between our two
groups. In this respect, our study did not confirm the existence of perceptual bias in
depression. Indeed, so far there have been discrepant findings of the previous studies
about the presence of impairments in the decoding of facial expressions. Some studies
revealed that depressed patients exhibited a general deficit in recognizing negative
emotional expressions mainly toward sadness, fear, and anger (Surguladze et al.,
Mendlewicz et al., 2005). However, similar to our findings, Weniger et al. (2004) found
that depressive individuals were able to recognize all of the facial expressions as
correctly as normal individuals were.
In conclusion, more or less our findings add to a growing body of evidence
demonstrating an important effect of emotion on different aspects of cognitive
processing.
4. 4. Reaction Times for Accurate Responses towards Emotional Facial Expressions
One of our purposes was to examine the quickness in their recognition of all
seven expressions in alcohol dependent individuals and healthy control individuals.
Contrary to our hypothesis, the results did not manifest any significant differences
between alcohol dependent individuals and non-dependent individuals in terms of total
reaction time scores toward all seven expressions. This result is not in line with previous
studies (e.g. Tedstone & Coyle, 2004; Foisy, 2007). This discrepancy between the
present results and those of former studies may be explained by some methodological
limitations.
90
4. 5. The Effects of Depression, State-Trait Anxiety, and Psychopathological
Symptoms on the Reaction Times for Accurate Responses towards Emotional
Facial Expressions
It has been well established that clinically or non-clinically anxious individuals
display an attentional bias toward the stimuli that they perceived to be threatening.
Therefore, we expected them to react more rapidly than normal control group. Similarly,
depression is counted as one of the disorders that affect the individuals’ positive
perception. Depressed individuals’ negative points of view toward self, world, and
future make them recognize expressions in a more negative manner, which might cause
an attentional bias especially toward sadness. Based on these perspectives, we
hypothesized that alcohol dependent individuals would perceive negative emotional
expressions, anger, fear, sadness, and disgust more rapidly than non-dependent
individuals. Nevertheless, the results demonstrated that alcohol dependent group
recognized only disgust facial expression significantly faster than non-dependent
individuals did. Additionally, findings indicated that BDI, STAI, and SCL-90-R did not
affect reaction time scores toward happiness, surprise, and neutral facial expressions.
These results are somehow inconsistent with prior findings. There is a
considerable amount of evidence have shown that especially clinically anxious
individuals, particularly individuals with social phobia and generalized anxiety disorders
were hyper-vigilant to threatening stimuli (e.g. Mansell et al., 2002; Mohlman, et al.,
2007; Mogg et al., 2000). In our study when state and trait anxiety levels were taken
under control, two groups differed in the reaction times only towards disgusted faces.
Alcohol dependent individuals perceived disgusted faces more quickly than non-
dependent individuals when their depression, anxiety levels were controlled.
The rapid recognition of disgusted faces of alcohol dependent inpatients may be
related to their high exposure of disgusted faces from the faces looking at them rather
than an existence of organic deficits. It is well documented that familiar faces are more
accurately recognized than non-familiar ones (e.g. Gallegos & Tranel, 2005; Elfenbein
& Ambady, 2003). Therefore, we may assume that familiar disgusted faces are more
recognizable than other faces so that they are reacted faster than others. Also, one of our
91
findings concluded that disgusted faces were confused with angry ones by alcohol
dependent inpatients. Specifically, alcohol dependent inpatients reacted faster towards
disgusted expressions which were perceived as angry because of their high familiarity
and high exposure levels of disgusted faces from the faces looking at them. This
misperception may cause such interpersonal conflicts and also social isolation. This
inference should be clarified by further research.
4. 6. Misinterpretations of Emotional Facial Expressions
In the current study, it was observed that both alcohol dependent individuals and
non-dependent individuals tended to respond all expressions almost similarly.
Specifically, only the group difference was obtained in the recognition of disgusted
faces. Then, we decided to find out their misinterpretation of responses towards all facial
expressions. Even though the total scores of inaccurate responses were less than accurate
ones for both groups, unfortunately accurate scores of control group were not high as
expected.
Results indicated that alcohol dependent individuals and non-dependent
individuals displayed similar misjudgments toward fearful, angry, surprised, and neutral
expressions except sad and disgusted. Happy expressions were not considered in this
context because of their obtaining of highest recognition scores for both groups. In
addition, the causes of misinterpretation of disgusted expression in alcohol dependent
individuals had already been discussed. Interestingly, it was observed that non-
dependent individuals perceived disgusted faces as surprised faces.
Differently from other emotional expressions, it was found that non-dependent
individuals perceived sad as neutral expression. On the other hand, alcohol dependent
individuals tended to misjudge sad faces as surprised faces.
Generally, the findings suggested that alcohol dependent individuals and non-
dependent individuals displayed similar tendencies toward neutral faces. Both groups
misjudged neutral faces as sad faces. Likewise, both groups failed to interpret angry
expression correctly and they assumed them as surprised expression.
92
Additionally, the most confusion between emotional expressions was observed in
the responses of surprised and fearful expressions for both groups. Both groups
misinterpreted fearful faces as surprised faces. The lowest scores belonged to fear
expressions for both groups. They exhibited a tendency to perceive surprised faces as
fearful faces. However, this error rate was less than the errors of fear expressions. In
other words, all participants were better in reading of surprised faces rather than fearful
faces.
The misinterpretations of facial expressions of both groups and unexpected poor
performance of non-dependent individuals may be explained by cultural differences.
Recently, substantial cross-cultural studies have pointed out the role of culture in the
identification of emotional expressions. Previous studies in which Japanese and
Caucasian Facial Expressions of Emotion (JACFEE) photo set were used showed that
especially Japanese individuals were different from Americans in terms of recognition of
fearful faces. These studies exhibited that Japanese individuals mistook fearful faces for
surprised ones same as our findings (Russell et al., 1993; Shioiri et al., 1999). Komaki et
al. (2006) found that Japanese participants were not able to discriminate fearful faces
properly from surprised faces. Additionally these individuals could not perceive fearful
faces as a threatening stimulus. On the other hand, non-Japanese individuals easily
recognized fearful expressions. In conclusion, Komaki et al. (2006) discussed their
findings and explained their doubts about the universality of facial expressions.
Likewise, Shioiri et al. (1999) postulated that Japanese participants had lower scores
than American participants in the recognition of all universally accepted expressions that
are anger, contempt, disgust, fear, happiness, sadness, and surprise. In addition, they did
more errors in the expressions of anger, disgust, fear, and sadness. Surprised and happy
are the easiest expressions to recognize similar to our findings. Authors explained the
distinctions that Japanese people tend to mask their negative emotional expressions
when the presence of an authority figures than Americans do. In this context, Japanese
and Turkish cultures may share common characteristics such as collectivism. Collective
cultures emphasize group cohesion, solidarity, and harmony unlike individualistic
cultures, which foster autonomy, separateness, and individuality (Matsumoto et al.,
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2002). People in individualistic cultures are more likely to show their emotions and they
feel more freely to express their emotions than people of collectivistic cultures. This
may help to explain the recognition differences between American and Japanese people
who display similarities with our culture.
On the other hand, the commonality of alcohol dependent individuals and non-
dependent individuals may be explained by familiarity issue. As it is known, people
have more positive beliefs and attribute more positive traits toward the members of their
own group. This in-group bias effect or in-group advantage or in other words, ethnic
bias can be responsible for these discrepant results. Most of the studies about culture-
specific recognition of facial expressions have proved that participants are more accurate
in the judgment of emotional expressions in which they have greater familiarity
(Elfenbein & Ambady, 2003; Beaupre & Hess, 2003). Gallegos & Tranel (2005)
demonstrated that personally familiar faces were recognized both accurately and faster
even they were neutral than other faces. In this respect, unfamiliar facial expressions that
were used in this study might have affected the accuracy of interpretations.
Furthermore, these observed culture specific rules of decoding may be resulted
from morphological characteristics of pose of faces. Namely, disgusted may be more
recognizable expression than others because of its salient nose wrinkle pose. However,
fearful and surprised expressions may be more difficult to categorize because of their
shared pose characteristics of a face. According to Gosselin and Larocque (2000) the
reason of misinterpretations are that, the more similarities one emotion shares with
another, the more likely to be perceived inaccurately and to be confused with each other.
This explanation can be conceivable in order to explain the confusion of fearful and
surprised faces, such as raising the eyebrows together; however, this approach does not
explain the confusion of sad and neutral expressions.
One of the interesting findings in our study was the confusion of the facial
expressions of neutral and sadness. Specifically, both alcohol dependent and non-
dependent healthy group misidentified neutral faces as sad faces. One possible
explanation of this finding includes the negative perceptual bias of depression.
Cognitive theories of depression proposed that depressed individuals tend to interpret
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ambiguous information in a negative manner. Hence, these patients are usually expected
to judge facial stimuli more negative than do controls. Mogg et al. (2006) suggested that
depressed patients made more negative interpretations and they showed more negative
recall than non-depressed patients did. Similarly, Leppanen et al. (2004) found that
depressed individuals attributed neutral faces to sad faces and recognized neutral
expressions both more slowly and less accurately than healthy participants did.
However, even though we obtained that, alcohol dependent individuals scored higher in
Beck Depression Scale, non-dependent individuals were not counted as depressed. Then
we interpret this common point as also cultural. An alternative explanation for this
outcome can be found in the literature about socio-economic status of participants.
Herba & Phillips (2004) exhibited that in their study, which preschool children were
used; deprived socio-economic groups were significantly at more risk for emotional
difficulties. Their findings indicated that socio-economically disadvantaged children
were more accurate on fearful expression. The authors suggested that exposure of high
stress living conditions may cause an improvement of a bias which has a survival value.
Perhaps, high stress, low income, low life standards, and decreased expectations might
have caused our sample to attribute neutral stimuli to sadness. Future studies should
take into account such factors.
4.7. The Roles of BDI, STAI-S, SCL-90, Recognition of Disgust and Fear Emotional
Expressions in the Prediction of Alcoholism
Eventhough, we do not have enough number of participants, we examined
whether alcohol dependence based on CAGE scores would be predicted by
demographical variables such as age and education; by psychological symptoms scores
obtained from Beck Depression Inventory, State-Trait Anxiety Inventory, and Symptom
Checlikst (SCL-90) and its nine subscales-anxiety, depression, phobic anxiety, hostility,
interpersonal sensitivity, obsessive-compulsion, somatization, psychotizm, and paranoid
ideation; by recognition scores from each seven emotional facial expressions; and by
reaction time scores toward accurately recognized facial expressions. As a result
stepwise regression analyses, whereas obsessive-compulsive subscale of SCL-90,
95
depression level obtained from Beck Depression Inventory, and recognition accuracy
scores of fearful facial expressions positively associated with the level of alcohol
consumption, recognition accuracy scores of disgusted facial expression and scores from
STAI- State Anxiety Form negatively associated with the presence of alcohol
dependence.
These findings are in agreement with previous studies. Several studies have
reported that individuals who are dependent on psychoactive substances have a higher
prevalence of anxiety disorders (e.g. Gratzer et al., 2004; Ceylan & Turkcan, 2003,
p.59-63; Nolen-Hoeksema, 2004; Hoes, 1997; Merikangas et al., 1998; Wetterling and
Junghanns, 2000; Preisig et al., 2001; Devanand, 2002; Tedstone & Coyle, 2004; Terra
et al., 2006). There is a hypothesis, which includes that alcoholism is a result of self-
medication or anxiety management technique. Specifically, this hypothesis suggests that
alcohol is used to reduce the anxiety levels of individuals. Although it has not been
proved, previous studies revealed that there was a prevalence of 30.6% was for specific
phobia, 24.7% for social phobia, 19.3% for generalized anxiety disorder, 5% for
obsessive-compulsive disorder, 4.6% for posttraumatic stress disorder, and 2% for panic
disorder with agoraphobia among alcohol dependent patients (Terra et al., 2006).
However, none of the studies up to now has established a direct relationship between
obsessive-compulsive disorder and alcoholism. Among anxiety disorders, social phobia
plays a remarkable role than obsessive-compulsive disorder. Nevertheless, it is also
noteworthy that alcoholism has some similarities between some aspects of obsessive-
compulsive disorder in terms of craving features in alcoholism. The concept craving
can be defined as “a compelling urge” intruding into thoughts and changing both mood,
and behavior of an addicted individual (Janiri et al., 2004). It concerns drinking
intention, and feelings in the event of conflict between desire and abstinence. The
symptom checklist (SCL-90) that was given to participants has totally 10 items for
measuring obsessive-compulsive characteristics of an individual. These items generally
focus on the difficulty on performing daily chores and making decisions, concentration
problems, and distress of unwanted and uncontrollable thoughts and behaviors
(compulsions). Therefore, alcohol dependent individuals might have filled these items
96
while considering their severity of withdrawal, problems in the performance of daily
duties during alcohol intake. The present findings highlight the need for further studies
to determine the relationship between OCD and alcoholism.
Another finding of our regression analysis was that state anxiety played a
negative role in the prediction of the existence of alcoholism. Most of the studies have
pointed out the relationship between alcoholism and self-medication hypothesis, which
is mentioned above. Briefly, this hypothesis includes that the reason of using alcohol is
to decrease the tension of individual (Kushner et al., 2001). However, in our study we
found an opposite direction in the relationship between alcoholism and state anxiety
level of an individual. In our study, it was also found that alcohol dependent individuals
did not get higher scores from STAI-S significantly from non-dependent individuals.
These both findings can be resulted from medicational treatment of our alcohol
dependent inpatients, since anxiolytic drugs helps to diminish situational anxiety of
patients. However, since there are studies, which failed to find such a relationship
between decreased State Anxiety level and increased alcohol consumption (vice versa)
should be replicated by other researchers.
One of the findings in stepwise regression analysis was that depression scores
predicted positively the presence of alcoholism. This result is consistent with several
lines of previous work. Devanad et al. (2002) suggested that in depressed individuals,
the prevalence of alcohol use/abuse is three to four times greater than in non-depressed
individuals. Similarly, in a study of Gratzer et al. (2004), their findings revealed that
there was a significantly higher rate of alcohol abuse or dependence in the co-morbid
depression and anxiety group than in the pure anxiety disorder group. In this respect, the
co-morbid depression and anxiety group seem to have the greatest risk of alcohol abuse
or dependence in both females and males. Of these participants, 45% reported anxiety
as the first disorder, 30% reported alcohol dependence as the first disorder, while 10%
reported depression as the first disorder, and rest of 15% reported all three begun
simultaneously. Briefly, depression seems to have a stronger association with alcohol
misuse or alcoholism than anxiety disorders especially for females and all age groups.
97
However, it remains unclear whether alcoholism occurs secondary to mood and anxiety
disorders or is a primary cause of these disturbances.
Fourth step in our regression analysis revealed that impaired recognition of
disgusted faces predicted significant but modest (R2=.30) the existence of alcoholism.
Over the past decades, there has been a growing interest of in the role of disgusted facial
expression in psychopathology. Kornreich et al. (2001) indicated that alcoholic patients
had significantly less accuracy scores than obsessive-compulsive patients and normal
individuals. Alcohol dependent individuals had impaired recognition especially towards
the expressions of happiness, anger, disgust, sadness, but not fear. In another study of
Kornreich et al. (2003) their results revealed that accuracy scores were significantly
lower in alcohol dependent individuals than normal individuals. In line to previous
studies, Townshend et al. (2003) found that alcohol dependent individuals exhibited
inappropriate responses in the identification of angry and disgusted facial expressions.
Accordant with the existing findings, our study confirms that alcohol dependent
individuals tend to show a deficit in the recognition of disgusted expression. And
inaccurate identification of disgusted facial expression seems to be contributed
significantly to the explanation of alcoholism.
Final step of the regression analysis revealed that accurate recognition of fearful
faces significantly predicted the presence of alcoholism. In this study, other analyses
had revealed that alcohol dependent inpatients had responses that were more accurate in
the identification of toward fearful expressions when compared to other expressions and
non-dependent individuals. However, this difference was not statistically significant.
Indeed, this finding seems to be parallel only to the findings of Townshend and Duka
(2003). Their study manifested that alcohol dependent inpatients showed an enhanced
intensity of fear recognition. The authors interpreted this increased fear perception may
be the result of a hyperactivity of the amygdala, since neuro-psychological data suggests
that fearful expressions activate amygdala (Blair et al., 2004). That interpretation may
highlight the efficacy of detoxification and medical treatment on the amygdala, which
had become damaged due to long-term alcohol dependence. Surely, further studies are
98
required to clarify the association of the dysfunction of amygdala with increased fear
recognition.
To sum up, this regression analysis provided further evidences in the explanation
of alcoholism. More or less, these findings can highlight new treatment models and can
imply further research issues.
4. 8. General Discussion and Conclusions
The current study examined the presence of any impairment in the recognition of
emotional facial expressions in alcohol dependence. It was also investigated the
existence of attentional and evaluative bias of state-trait anxiety and depression by
measuring the reaction times of facial expressions. At the end of study, we concentrated
on what kind of variables would predict an existence of alcoholism.
To begin with, our findings have confirmed the existing literature that alcohol
dependence co-morbids to anxiety disorders and depression. We found that alcohol
dependent individuals obtained higher scores on both State-Trait Anxiety Inventory and
Beck Depression Inventory.
On the other hand, the general results did not support our hypothesis that alcohol
dependent group would have less accurate scores than non-dependent group in the
recognition of all emotional expressions. However, it was found that alcohol dependent
group differed significantly from non-dependent group only in the identification of
disgusted expression. Specifically, alcohol dependent group did more errors in decoding
of disgusted faces, which were confused with angry ones. This misinterpretation is
consistent with several studies (e.g.Townshend & Duka, 2003; Philippot et al., 1999).
These authors interpreted this confusion as the damage or a reduction in the functioning
of orbitofrontal cortex, which plays the major role in discriminating of these emotions
because of long-term alcohol misuse. The misjudgment of anger expression may
suggest that alcohol dependent individuals feel more sensitive to threat from faces
looking at them and they are more likely to judge facial expressions as hostile rather
than disgusted or angry faces. Thus, inaccurate decoding of these expressions may cause
99
alcohol dependent individuals to misunderstand their friends or relatives’ intentions and
feelings, which interrupt the flow of conversation and may result more social-isolation.
Interestingly, findings revealed that both alcohol dependent and non-dependent
individuals discriminated fearful faces less than other emotional expressions. Both
groups had the minimum scores toward fearful faces when compared to other
expressions. Instead, they misinterpret fearful faces as surprised faces. However, it is
difficult to explain why non-dependent individuals showed a similar tendency.
Additional to this confusion, both groups had similar misjudgments toward anger and
neutral expressions except sadness and disgust. As predicted, happy expressions were
the most recognizable expression for both groups. This finding is in agreement with
previous studies.
On the other hand, our regression analysis demonstrated that correct recognition
of fearful faces was one of the predictors in the presence of alcohol dependence. One
possible explanation depends on a neuro-psychological approach, which is that the
increased fear perception is a kind of overcompensation of the amygdala (Townshend &
Duka, 2003; Blair et al., 2004). This interpretation may highlight the efficacy of
detoxification and medical treatment of the amygdala. An alternative explanation for
this finding includes socio-economic status of alcohol dependent inpatients. According
to Herba & Phillips (2004) deprived socio-economic level significantly causes greater
risk for emotional difficulties. The authors stated that exposure of high stress, low
income, low life standards, and decreased expectations may play a role in the
improvement of the perception of fearful expressions. Further studies may focus on the
socio-economic status of participants in terms of emotional perception.
Furthermore, we tested the impacts of depression, state-trait anxiety levels, and
nine psychopathological symptoms (Somatization, Obsessive-Compulsions,
Interpersonal Sensitivity, Depression, Anxiety, Hostility, Psychotism, Paranoid Ideation,
and Phobic Anxiety) on the recognition of facial expressions and reaction times toward
these facial expressions to point out the presence of attentional or evaluative bias of
depression and state-trait anxiety. Surprisingly, our findings manifested that alcohol
dependent group differed only in the identification of disgusted faces. And they reacted
100
towards disgusted faces more rapidly than non-dependent groups. In other words,
alcohol dependent individuals recognized less but responded faster towards disgusted
expression than non-dependent individuals did when depression, state-trait anxiety
levels were controlled. Therefore, our findings have suggested that there has an impact
of depression and state-trait anxiety levels on the identification of facial expressions.
The literature up to now has contained discrepant findings about selective
attention or misinterpretation of depression and state-trait anxiety in the recognition of
facial expressions. Whereas, it has been difficult to infer stable conclusions from both
our study and previous studies, the impairment and rapid reactions to disgusted faces in
alcohol dependence should be reconsidered.
To conclude, this study has provided further evidences for impaired recognition
of emotional facial expressions in the alcohol dependent group when compared to the
control group. In addition, it implies the roles of depression and state-trait anxiety in
information processing system.
4. 9. Limitations of the Present Study
Surely, some limitations need to be acknowledged in our study.
For both alcohol dependent and non-dependent samples, besides using self-
reported measures, a use of a computerized Emotional Recognition Test might constitute
one of the methodological limitations. Because, computerized material was novel and its
psychometric properties were not documented. Also, it may need more sophistication
than just filling in the self-report inventories. Therefore, some of the participants may
not feel familiar to computerized material, which may affect the performances.
One of the important limitations may be that all data were collected during
business hours for the control group, even though interruptions were prevented, this
factor may cause a decline in their performances. This might have restricted the validity
of our findings.
The selection of the control group may constitute a weakness of our study. They
were chosen mostly from courthouses, from different positions; nevertheless, they may
not be a representative of a population.
101
Additionally, the control group of this study represented non-clinical individuals.
Thus, they should have been asked whether they were in treatment for any psychological
disorder, if so they should have been excluded from the study. Only potential alcohol
dependent individuals and psychotics were excluded.
One of the important shortcomings of our study may be a low number of all
participants, even though experimental studies require low number of participants when
compared to general studies, this situation inevitably may reduce the ecological validity.
Another potential problem is related to medication of alcohol dependent
inpatients. All of the patients were under treatment when they were administered to all
measures. The impact of medication (anxiolytics or antidepressants) could reduce
particularly the state anxiety levels of patients and affect the reaction time scores. As a
result, this might have affected their ratings of their feelings of anxiety on both State
Anxiety Inventory and the accuracy level on recognition of facial expressions. It could
have been better to study the first time alcohol dependent patients who were not under
medication. However, as this condition was rare, the patients under medication were
conveniently included to the study.
One of the limitations is related with the time of administration of all measures to
alcoholic inpatients. Indeed, it could have been better to test them after their
hospitalization process is over. Because, their anxiety levels resulting from withdrawal
of alcohol abuse could have affected their scores on State –Trait Anxiety Inventory and
Symptom Checklist. Nevertheless, it would be more difficult to reach the individuals
after their hospitalization are ended because of their settlements out of İstanbul.
Finally, one of the critical weaknesses of our study is about gender issue. Hence,
in almost all societies to reach female alcohol dependent individuals is very difficult,
therefore we decided to use only male individuals. The present study should have rather
included a mixed-gender sample of both groups. A large body of evidences has shown
that females are more skilled in emotion processing because of their empathy, emotional
understanding abilities (e.g. Herba & Phillips, 2004; Thayer & Johnsen, 2000).
Therefore, in order to test this assumption and to determine whether there would be
102
accuracy differences in the identification of facial expressions and their pattern of errors,
it is prominent to carry out a study in which females will participate.
4. 10. Clinical Implications
Emotion identification is very critical for social interaction and daily functioning.
The ability to recognize facial expressions is an important component of social
interaction in order to interpret the intentions, goals, opinions and attitudes of people
(Erickson & Schulkin, 2003; Batty & Taylor, 2003). It is very important to know how
people experience emotions in terms of the quality of relationship. However, any small
impairment in the recognition of facial expressions may interrupt the flow of
conversation and hence may cause interpersonal conflicts.
Alcoholism is characterized by multiple neuropsychological dysfunctions and by
profound interpersonal relationship problems and social isolation (Kornreich, et al.,
2001). As predicted, alcohol dependent participants were found as less accurate in
identifying seven emotional expressions (happiness, sadness, fear, anger, surprise,
disgust, and neutral) although we failed to reach statistical significance. Specifically,
alcohol dependent individuals showed a significant error rate in decoding of disgusted
expression. Instead, they misjudge disgusted faces as angry ones. This can be a toxic
result of heavy alcohol consumption. The misjudgment may suggest that alcohol
dependent individuals are more sensitive to the feelings of threat on faces looking at
them and they are more likely to interpret facial expressions as hostile rather than
disgusted or angry. Also, the number of fear recognition in alcohol dependents was
much more than non-dependents, this issue should be replicated.
Furthermore, stepwise multiple regression analysis indicated that obsessive-
compulsive subscale of symptom checklist, Beck Depression Inventory, STAI-State
Form, and the recognition of fearful as well as disgusted expressions were associated
with alcoholism. Briefly, this analysis highlight that the increased fear recognition,
decreased disgust recognition and the existence of depression and obsessive-compulsive
features, and reduced state anxiety levels are related with the alcohol dependence. In
order to find out most appropriate treatment model of alcoholism, it is also important to
103
understand the nature of alcoholism. Thereby, the implications of regression analysis
may be considered.
Similar findings were obtained when state-trait anxiety levels, depression, and
other psychopathological symptoms were taken as covariates. In other words, alcohol
dependent individuals recognized less but responded faster toward disgusted expressions
than non-dependent individuals when covariates were considered. Surely, it has been
well established that anxious individuals exhibit an attentional bias toward threat cues.
This bias may play an important role in the development and maintenance of anxiety. If
these biases provoke anxiety states, then removal of biases can be a target of treatment.
However, when we consider our findings that failed to indicate the existence of any bias,
then treatment can be regenerated through this novel finding.
Specifically, our general findings provide more information to the clinicians in
order to realize the co-morbid disorders, cognitive impairments, and social isolation of
long-term alcohol abuse in a more comprehensive manner. Consequently, new treatment
techniques can be produced through decreased inaccurate decoding and reduced
functioning of brain areas that are responsible for the process of disgusted expression.
As conclusion, most of the literature up to now has focused on cognitive
deficiencies of long-term alcohol abuse. In the current study, the main objective was to
determine whether the alcohol dependence would decrease the ability of emotional facial
expressions. In terms of the design and objectives, this is the first study in Turkey on the
identification of emotional facial expressions in alcohol dependent individuals.
4. 11. Directions for Future Research
The results of the present study in general did not support our hypothesis, which
was that alcohol dependent individuals would show inaccurate identification of facial
expressions. Additional studies are needed to clarify the nature of this relationship.
Future research should examine the presence of any impairment both in a larger sample
and with a mixed-gender sample. Because considerable amount of evidences have
proved that females are better in detecting and decoding facial expressions. They have
been also found as more emotionally expressive than males (e.g. Herba & Phillips, 2004;
104
Thayer & Johnsen, 2000). Moreover, it may be advisable for future studies to use
instrument, which are as ecologically valid as possible.
In order to find out the relationship between interpersonal problems and
impairments in the recognition of facial expressions properly, it will be better to use a
measure such as Inventory of Interpersonal Problems. Thus, if interpersonal difficulties
are reported, these difficulties can be correlated with facial decoding problems. Then, it
will be proved that non-verbal emotional cues play an important role in maintenance of
interpersonal communication.
Furthermore, common identifications of facial expressions of both groups let us
consider some cultural elements. The confusion of fearful and surprised faces, the
misjudgment of neutral faces as sad ones can be counted as the examples of the
commonalities. Perhaps, environmental conditions and socio-economic status may take
role in these misinterpretations. Definitely, concept of the universality of facial
expressions and their recognitions may need to be reconsidered. Similarly, our findings
yielded that there was an increased recognition in fearful expression in alcohol
dependent individuals, eventhough this difference did not reach a statistical significance.
Therefore, further research is needed to resolve these issues.
105
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APPENDICES
Appendix A
DEMOGRAPHICAL INFORMATION
1. ID No: ............ 2. Tarih: .... 3. Ad ve Soyadınız: 4. Yaşınız: ........... 5. Oturduğunuz şehir: ........... 6. Mesleğiniz:
a. İşçi b. Memur c. Serbest Meslek d. Emekli e. Sanatçı f. Ev hanımı g. İşsiz h. Diğer ................
7. Eğitiminiz:
a. Okuma yazma biliyorum b. İlkokul mezunu c. Ortaokul mezunu d. Lise mezunu e. Üniversite mezunu f. Yüksek lisans ya da doktora
8. Hayatınızda en uzun süre oturduğunuz yer:
a. Büyükşehir b. Şehir c. Kasaba d. Köy 9. Medeni Durumunuz:
a. Bekar b. Evli c.Boşanmış d. Ayrı Yaşıyor
10. Çocuğunuz var mı? a. Var ............tane b. Yok
11. Ailenizde sizden başka alkol kullanan var mı? Var ise kaç yıldır devam ediyor?
...................................................................
12. Alkol sorununuz kaç yıldır devam ediyor? .................................................
13. Alkol sorunu nedeniyle kaç kez hastaneye yattınız? .................................................
14. Sizce alkol sorununuzun nedeni nedir? ……………………………………………………….
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Appendix B
CAGE ALCOHOL USE INVENTORY
1. Şimdiye kadar içmeyi kesmeniz ya da azaltmanız gerektiğini hissettiniz mi?
a. Evet b. Hayır
2. İçmenizle ilgili olarak başkalarının eleştirilerinden sıkıldığınız oldu mu? a. Evet b. Hayır 3. Hiç şimdiye kadar içmenizden dolayı kendinizi kötü ya da suçlu hissettiniz mi? a. Evet b. Hayır 4. Hiç şimdiye kadar sinirlerinizi yatıştırmak ya da akşamdan kalma halinizi gidermek amacıyla sabah ilk iş olarak içtiniz mi? a. Evet b. Hayır
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Appendix C
BECK DEPRESSION INVENTORY (BDI)
YÖNERGE: Her gruptaki cümleleri dikkatle okuyunuz ve BUGÜN Dahil, GEÇEN HAFTA içinde kendinizi nasıl hissettiğinizi en iyi anlatan cümleyi seçiniz. Seçmiş olduğunuz cümlenin yanındaki numarayı daire içine alınız. 1. 0 Kendimi üzüntülü ve sıkıntılı hissetmiyorum.
1 Kendimi üzüntülü ve sıkıntılı hissediyorum. 2 Hep üzüntülü ve sıkıntılıyım. Bundan kurtulamıyorum. 3 O kadar üzüntülü ve sıkıntılıyım ki artık dayanamıyorum.
2. 0 Gelecek hakkında umutsuz ve karamsar değilim. 1 Gelecek hakkında karamsarım. 2 Gelecekten beklediğim hiçbir şey yok. 3 Geleceğim hakkında umutsuzum ve sanki hiç bir şey düzelmeyecekmiş gibi geliyor. 3. 0 Kendimi başarısız bir insan olarak görmüyorum. 1 Çevremdeki bir çok kişiden daha çok başarısızlıklarım olmuş gibi hissediyorum. 2 Geçmişime baktığımda başarısızlıklarla dolu olduğumu görüyorum. 3 Kendimi tümüyle başarısız bir kişi olarak görüyorum.
4. 0 Birçok şeyden eskisi kadar zevk alıyorum. 1 Eskiden olduğu gibi her şeyden hoşlanmıyorum. 2 Artık hiçbir şey bana tam anlamıyla zevk vermiyor. 3 Her şeyden sıkılıyorum. 5. 0 Kendimi herhangi bir şekilde suçlu hissetmiyorum. 1 Kendimi zaman zaman suçlu hissediyorum 2 Çoğu zaman kendimi suçlu hissediyorum.
3 Kendimi her zaman suçlu hissediyorum. 6. 0 Kendimden memnunum. 1 Kendimden pek memnun değilim. 2 Kendime çok kızıyorum. 3 Kendimden nefret ediyorum. 7. 0 Başkalarından daha kötü olduğumu sanmıyorum. 1 Zayıf yanlarım ya da hatalarım için kendi kendimi eleştiririm. 2 Hatalarımdan dolayı her zaman kendimi kabahatli bulurum. 3 Her aksilik karşısında kendimi kabahatli bulurum.
120
8. 0 Kendimi öldürmek gibi düşüncelerim yok 1 Zaman zaman kendimi öldürmeyi düşündüğüm oluyor fakat yapmıyorum 2 Kendimi öldürmek isterdim. 3 Fırsatını bulsam kendimi öldürürüm. 9. 0 Her zamankinden fazla içimden ağlamak gelmiyor.
1 Zaman zaman içimden ağlamak geliyor. 2 Çoğu zaman ağlıyorum. 3 Eskiden ağlayabilirdim şimdi istesem de ağlayamıyorum.
10. 0 Şimdi her zaman olduğumdan daha sinirli değilim. 1 Eskisine kıyasla daha kızıyor ya da sinirleniyorum. 2 Şimdi hep sinirliyim. 3 Bir zamanlar beni sinirlendiren şeyler şimdi hiç sinirlendirmiyor. 11. 0 Başkaları ile görüşmek, konuşmak isteğimi kaybetmedim. 1 Başkaları ile eskisinden daha az konuşmak, görüşmek istiyorum. 2 Başkaları ile konuşma ve görüşme isteğimi kaybettim. 3 Hiç kimseyle görüşüp, konuşmak istemiyorum. 12. 0 Eskiden olduğu kadar kolay karar verebiliyorum. 1 Eskiden olduğu kadar kolay karar veremiyorum. 2 Karar verirken eskisine kıyasla çok güçlük çekiyorum. 3 Artık hiç karar veremiyorum. 13. 0 Aynada kendime baktığımda bir değişiklik görmüyorum. 1 Daha yaşlanmışım ve çirkinleşmişim gibi geliyor 2 Görünüşümün çok değiştiğini ve daha çirkinleştiğimi hissediyorum. 3 Kendimi çok çirkin buluyorum. 14. 0 Eskisi kadar iyi çalışabiliyorum 1 Bir şeyler yapabilmek için gayret göstermek gerekiyor. 2 Herhangi bir şeyi yapabilmek için kendimi çok zorlamam gerekiyor. 3 Hiçbir şey yapamıyorum. 15. 0 Her zamanki gibi iyi uyuyabiliyorum 1 Eskiden olduğu gibi iyi uyuyabiliyorum. 2 Her zamankinden 1-2 saat daha erken uyanıyorum ve tekrar uyuyamıyorum. 3 Her zamankinden çok daha erken uyanıyorum ve tekrar uyuyamıyorum. 16. 0 Her zamankinden daha çabuk yorulmuyorum. 1 Her zamankinden daha çabuk yoruluyorum. 2 Yaptığım hemen herşey beni yoruyor. 3 Kendimi hiçbir şey yapamayacak kadar yorgun hissediyorum
121
17. 0 İştahım her zamanki gibi 1 İştahım eskisi kadar iyi değil. 2 İştahım çok azaldı 3 Artık hiç iştahım yok 18. 0 Son zamanlarda kilo vermedim 1 İki kilodan fazla verdim 2 Dört kilodan fazla kilo verdim 3 Altı kilodan fazla kilo verdim. Daha az yiyerek kilo vermeye çalışıyorum. Evet ........... Hayır.......... 19. 0 Sağlığım beni fazla endişelendirmiyor. 1 Ağrı, sancı, mide bozukluğu veya kabızlık gibi rahatsızlıklar beni endişelendiriyor. 2 Sağlığım beni endişelendirdiği için başka şeyler düşünmek zorlaşıyor. 3 Sağlığım hakkında o kadar endişeliyim ki başka hiçbir şey düşünemiyorum. 20. 0 Son zamanlarda cinsel konulara olan ilgimde bir değişme fark etmedim. 1 Cinsel konularla eskisinden daha az ilgiliyim. 2 Cinsel konularla şimdi çok daha az ilgiliyim 3 Cinsel konulara olan ilgimi tamamen kaybettim 21. 0 Bana cezalandırılmışım gibi gelmiyor. 1 Cezalandırılabileceğimi seziyorum
2 Cezalandırılmayı bekliyorum 3 Cezalandırıldığımı hissediyorum.
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Appendix D
STATE-TRAIT ANXIETY INVENTORY (STAI)
Yönerge: Aşağıdaki kişilerin kendilerine ait duygularını anlatmakta kullandıkları bir
takım ifadeler verilmiştir. Her ifadeyi okuyun, sonra da on anda nasıl hissettiğinizi
ifadelerin sağ tarafındaki seçeneklerden uygun olanını daire içine alın. Doğru ya da
yanlış yanıt yoktur. Herhangi bir ifadenin üzerinde fazla zaman harcamadan anında nasıl
hissettiğinizi gösteren yanıtı işaretleyin.
Hiç
Biraz
Çok
Tamamıyla
1. Şu an sakinim 1 2 3 4
2. Kendimi emniyette hissediyorum. 1 2 3 4
3. Şu an sinirlerim gergin. 1 2 3 4
4. Pişmanlık duygusu içindeyim 1 2 3 4
5. Şu anda huzur içindeyim 1 2 3 4
6. Şu anda hiç keyfim yok 1 2 3 4
7. Başıma geleceklerden endişe ediyorum. 1 2 3 4
8. Kendimi dinlenmiş hissediyorum.
1 2 3 4
9. Şu anda kaygılıyım. 1 2 3 4
10. Kendimi rahat hissediyorum. 1 2 3 4
11. Kendime güvenim var 1 2 3 4
12. Şu anda asabım bozuk. 1 2 3 4
13. Çok sinirliyim 1 2 3 4 14. Sinirlerimin çok gergin olduğunu hissediyorum.
1 2 3 4
15. Kendimi rahatlamış hissediyorum 1 2 3 4
16. Şu anda halimden memnunum 1 2 3 4
123
Hiç
Biraz
Çok
Tamamıyla
17. Şu anda endişeliyim. 1 2 3 4
18. Heyecandan endimi şaşkına dönmüş hissediyorum.
1 2 3 4
19. Şu anda sevinçliyim 1 2 3 4
20. Şu anda keyfim yerinde 1 2 3 4
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Yönerge: Aşağıdaki kişilerin kendilerine ait duygularını anlatmakta kullandıkları bir
takım ifadeler verilmiştir. Her ifadeyi fazla zaman harcamadan okuyun, sonra da genelde
nasıl hissettiğinizi ifadelerin sağ tarafındaki seçeneklerin uygun olanını daire içine alın.
Doğru ya da yanlış yanıt yoktur.
Hiçbir zaman
Bazen
Çoğu zaman
Her zaman
21. Genellikle keyfim yerindedir. 1 2 3 4
22. Genellikle çabuk yorulurum. 1 2 3 4
23. Genellikle kolay ağlarım. 1 2 3 4
24. Başkaları kadar mutlu olmak isterim. 1 2 3 4
25. Çabuk karar veremediğim için fırsatları kaçırırım.
1 2 3 4
26. Kendimi dinlenmiş hissederim 1 2 3 4
27. Genellikle sakin, kendime hakim ve soğukkanlıyım
1 2 3 4
28. Güçlüklerin yenemeyeceğim kadar biriktiğini hissederim.
1 2 3 4
29. Önemsiz şeyler hakkında kaygılanırım. 1 2 3 4
30. Genellikle mutluyum. 1 2 3 4
31. Herşeyi ciddiye alır ve etkilenirim. 1 2 3 4
32. Genellikle kendime güvenim yoktur.
1 2 3 4
33. Genellikle kendimi emniyette hissederim. 1 2 3 4
34. Sıkıntılı ve güç durumlarla karşılaşmaktan çekinirim.
1 2 3 4
35. Genellikle kendimi hüzünlü hissederim. 1 2 3 4
36. Genellikle hayatımdan memnunum. 1 2 3 4
125
Hiçbir zaman
Bazen
Çoğu zaman
Her zaman
37. Olur olmaz düşünceler beni rahatsız eder. 1 2 3 4
38. Hayal kırıklıklarını öylesine ciddiye alırım ki hiç unutamam.
1 2 3 4
39. Aklı başında ve kararlı bir insanım. 1 2 3 4
40. Son zamanlarda kafama takılan konular beni tedirgin eder.
1 2 3 4
126
Appendix E
THE SYMPTOM CHECKLIST (SCL-90-R)
Yönerge: Aşağıda zaman zaman herkeste rastlanılabilecek şikayetlerden oluşan bir liste
verilmiştir. Her soruyu dikkatle okuyunuz. Sözü geçen problemlerin son 1 Hafta içinde
sizi ne ölçüde rahatsız ettiğini göz önünde tutarak, yandaki sütundaki rakamlardan birini
işaretleyiniz. Hiçbir soruyu atlamayınız.
0 Hayır hiç 1 Biraz 2 Orta Derecede 3 Fazla 4 Çok Fazla 1. Baş Ağrıları 0 1 2 3 4
2. Sinirlilik veya içinizin titrediği hissi 0 1 2 3 4
3. Kafanızdan atamadığınız, tekrarlayan, hoşa gitmeyen düşünce ve sözcükleri
0 1 2 3 4
4. Baygınlık hissi veya baş dönmesi 0 1 2 3 4
5. Cinsel ilgi, istek ya da hazda azalma 0 1 2 3 4
6. Başkalarını eleştirmeye yatkınlık 0 1 2 3 4
7. Herhangi birinin düşüncelerini yönetecebileceğiniz hissi 0 1 2 3 4
8. Zorluk ve sıkıntılarınızdan başkalarından sorumlu olduğu duygusu
0 1 2 3 4
9. Hafıza zayıflığı, hatırlamada güçlük 0 1 2 3 4
10. Sakarlık, dikkatsizlik veya ihmallerin sizi rahatsız etmesi
0 1 2 3 4
11. Kolayca sinirlenme veya huzursuz olma 0 1 2 3 4
12. Kalp veya göğüs üzerinde ağrı 0 1 2 3 4
13. Cadde veya açık alanlarda korku duyma 0 1 2 3 4
14. Enerji, güç azalması, hareket ve düşüncede yavaşlama 0 1 2 3 4
15. Yaşamınıza kendi elinizle son verme düşüncesi 0 1 2 3 4
16. Başkalarının duymadığı sesler işitme 0 1 2 3 4
17. Titreme 0 1 2 3 4
18. İnsanların çoğuna güvenilemeyeceği duygusu 0 1 2 3 4
127
19. İştahsızlık 0 1 2 3 4
20. Ağlamaya yatkınlık 0 1 2 3 4
21. Karşı cinsle ilişkilerde çekingenlik, çaresizlik 0 1 2 3 4
22. Tuzağa düşürülme, kapana kıstırılma duygusu 0 1 2 3 4
23. Nedensiz ani korkular 0 1 2 3 4
24. Kontrol edemeyeceğiniz öfke nöbeti ve duygusal patlamalar
0 1 2 3 4
25. Yalnız olarak evden çıkmaktan korku duyma 0 1 2 3 4
26. Bazı konularda kendini suçlama eğilimi 0 1 2 3 4
27. Bel ağrıları 0 1 2 3 4
28. Herhangi bir işe başlamada ve sürdürmede zolanma hissi
0 1 2 3 4
29. Yalnızlık hissi 0 1 2 3 4
30. Hüzün, iç sıkıntısı 0 1 2 3 4
31. Gereğinden çok tasalanma ve endişelenme 0 1 2 3 4
32. Hiçbir şeye ilgi duymama 0 1 2 3 4
33. Ürkeklik, korku duyma 0 1 2 3 4
34. Duygularınızın kolayca incinebilmesi ve alınganlık 0 1 2 3 4
35. Özel ve gizli düşüncelerinizin başkaları tarafından bilindiği hissi
0 1 2 3 4
36. Başkalarının sizi anlamadığı ve size ilgisiz olduğu duygusu
0 1 2 3 4
37. Başkalarının size dostça davranmadığı, sizden hoşlanmadığı duygusu
0 1 2 3 4
38. Doğru ve eksiksiz olmasını garantilemek için herşeyi çok yavaş yapma gereksinimi
0 1 2 3 4
39. Kalbinizin çok hızlı atması veya çarpması 0 1 2 3 4
40. Midede nahoş duygular ya da bulantı 0 1 2 3 4
41. Başkaları karşısında aşağılık duygusu 0 1 2 3 4
42. Kas ağrı ve sızıları 0 1 2 3 4
43. Başkalarının sizi gözlediği veya hakkınızda konuştuğu duygusu
0 1 2 3 4
44. Uykuya dalmakta güçlük çekme 0 1 2 3 4
45. Yaptığınız işleri tekrar tekrar kontrol etme zorunluluğu hissetme
0 1 2 3 4
128
46. Karar vermede güçlük çekme 0 1 2 3 4
47. Otobüs, trende yolculuk etmekten korkma 0 1 2 3 4
48. Nefes almada güçlük çekme 0 1 2 3 4
49. Nöbetler şeklinde ateş basması veya buz kesmesi 0 1 2 3 4
50. Sizi korkuttuğu için belirli olay, yer ve nesnelerden uzak durma
0 1 2 3 4
51. Zihinde boşluk duygusu 0 1 2 3 4
52. Bedeninizin çeşitli yerlerinde hissizlik, uyuşma veya karıncalanma
0 1 2 3 4
53. Boğazınızda yumru tıkandığı hissi 0 1 2 3 4
54. Gelecekle ilgili umutsuzluk 0 1 2 3 4
55. Dikkatinizi toplamada güçlük çekme 0 1 2 3 4
56. Bedeninizin bazı kısımlarında güçsüzlük 0 1 2 3 4
57. Gerginlik veya tedirginlik hissi 0 1 2 3 4
58. Kol ve bacaklarda ağırlık hissi 0 1 2 3 4
59. Ölüm veya ölmekle ile ilgili düşünceler 0 1 2 3 4
60. Aşırı yemek yeme 0 1 2 3 4
61.Başkaları size bakarken, hakkınızda konuşurken huzursuzluk ve rahatsızlık duyma
0 1 2 3 4
62. Aklınıza size ait olmayan düşüncelerin gelmesi 0 1 2 3 4
63. Birisine zarar ve acı verme, dövme, yaralama isteği 0 1 2 3 4
64. Sabahları erken uyanma 0 1 2 3 4
65.Dokunma, sayma ve yıkama gibi davranışları zorunluluk hissederek tekrarlama
0 1 2 3 4
66. Huzursuz, rahatsız uyku veya uykunuzun bölünmesi 0 1 2 3 4
67. Birşeyleri kırmak veya parçalamak için dayanılmaz istek duyma
0 1 2 3 4
68.Başkalarının paylaşmadığı düşünce, görüş ve inançlarının olması
0 1 2 3 4
69. Başkaları ile birlikteyken konuşma ve davranışlarınıza dikkat etme zorunluluğu hissetme
0 1 2 3 4
70. Sinema ve alışveriste olduğu gibi kalabalıktan
huzursuzluk duyma ve kaçınma
0 1 2 3 4
71. Herşeyin çok zor ve yorucu olduğu duygusu 0 1 2 3 4
129
72. Dehşet ve paniğe kapılma nöbetleri 0 1 2 3 4
73. Topluluk içinde yiyip içerken husursuzluk duyma 0 1 2 3 4
74. Sık sık tartışmalara girme ya da iddialaşma 0 1 2 3 4
75. Yalnız kaldığınızda sinirlilik veya huzursuzluk hissi 0 1 2 3 4
76. Başarılarınızın başkaları tarafından yeterince takdir edilmediği hissi
0 1 2 3 4
77. İnsanlarla birlikteyken bile yalnızlık duyma 0 1 2 3 4
78. Yerinizde duramayacak ölçüde huzursuzluk hissi 0 1 2 3 4
79. Değersizlik duyguları 0 1 2 3 4
80. Başınıza kötü birşey geleceği hissi 0 1 2 3 4
81. Yüksek sesle bağırma veya birşeyler fırlatma hissi 0 1 2 3 4
82. Topluluk içinde bayılmaktan korkma 0 1 2 3 4
83. Eğer fırsat verirseniz insanların sizi kullanacağı duygusu
0 1 2 3 4
84. Cinsellikle ilgili oldukça rahatsız edici hayal, düşünce ve duygularınızın olması
0 1 2 3 4
85. Suç ve günahlarınızdan dolayı cezalandırılmanız gerektiği düşüncesi
0 1 2 3 4
86. Dehşet veya korku uyandıran düşünce ve hayaller 0 1 2 3 4
87. Bedeninizde ciddi bir bozukluk olduğu düşüncesi 0 1 2 3 4
88. Başka birine karşı gerçek bir yakınlık duymama hissi 0 1 2 3 4
89. Suçluluk duygusu 0 1 2 3 4
90. Aklınızda herhangi bir bozukluk olduğu düşüncesi 0 1 2 3 4
130
Appendix F
SAMPLE of BASIC EMOTIONAL FACIAL EXPRESSIONS
ANGRY SAD NEUTRAL
FEARFUL HAPPY DISGUSTED
SURPRISED